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Lawton et al 2021 ACC/AHA/SCAI Coronary Revascularization Guideline

Circulation. 2022;145:e18–e114. DOI: 10.1161/CIR.0000000000001038 January 18, 2022 e63 CLINICAL STATEMENTS AND GUIDELINES

opioid use and hasten extubation5,6;  however, it did not uniformly reduce complications or length of stay in patients after CABG.7,8 More recently, cardiac surgical service lines have expanded on fast-track anesthetic agents and implemented enhanced recovery programs, which use more extensive phase-specific perioperative interventions. Such programs have been shown to prevent early postoperative complications, minimize exposure to opioid-based analgesia, and reduce time to extubation, time in the intensive care unit, and hospital length of stay after CABG.1-3 Components of such programs may include liberation of “nothing by mouth” status, bundled surgical site infection prevention, multimodal nonopioid analgesics, protocolized short-acting anesthetics, targetedorgan perfusion strategies, and early postoperative ambulation. Assessment of enhanced recovery programs has been generally limited to moderatesized observational studies, and additional research is required to determine the necessary features and implementation strategies. Providers may consider the use of specific anesthetic and monitoring modalities outlined in Table 11.

12.2 Bypass Conduits in Patients Undergoing

CABG Recommendations for Bypass Conduits in Patients Undergoing CABG Referenced studies that support the recommendations are summarized in Online Data Supplement 37.

COR LOE Recommendations

1 B-R 1.	 In patients undergoing isolated CABG, the use of a radial artery is recommended in preference to a saphenous vein conduit to graft the second most important, significantly stenosed, non–LAD vessel to improve long-term cardiac outcomes.1-3

1 B-NR 2.	 In patients undergoing CABG, an IMA, preferably the left, should be used to bypass the LAD when bypass of the LAD is indicated to improve survival and reduce recurrent ischemic events.4-9

2a B-NR 3.	 In patients undergoing CABG, bilateral IMA (BIMA) grafting by experienced operators can be beneficial in appropriate patients to improve long-term cardiac outcomes.3,10-12

Synopsis In the choice of conduits for CABG, both clinical and technical factors (eg, life expectancy, presence of diabetes, presence of CKD, degree of target stenosis) are considered (Table 12). Decades of data have supported the use of the LIMA to graft the LAD to prolong survival. These data are from observational studies and, for the most part, were derived before the introduction of current optimal medical therapy. The LIMA is preferable unless specific contraindications are present. The right IMA

Table 11.  Perioperative Anesthetic and Monitoring Considerations for CABG Anesthetic considerations Perioperative analgesia Nonopioid medications (eg, acetaminophen, ketamine, dexmedetomidine) and/or regional techniques (eg, truncal nerve blocks), particularly as part of a multimodal analgesic approach, have been shown to reduce perioperative opioid use in cardiac surgery.1-16 Maintenance anesthesia Although volatile (versus intravenous) anesthesia may facilitate earlier extubation,2,6-8,12,14 recent evidence suggests that the choice of maintenance anesthetic likely does not impact mortality rate after cardiac surgery.17-21 Mechanical ventilation An intraoperative lung-protective ventilation strategy (ie, tidal volume of 6–8 mL/kg predicted body weight + positive end-expiratory pressure) has been shown to improve pulmonary mechanics and reduce postoperative pulmonary complications.21-25 Goal-directed therapy Goal-directed therapy, which creates protocols for the use of fluids and vasopressors to target specific hemodynamic goals, has yielded inconsistent results and requires additional investigation to determine its use in cardiac surgery.26,27 TEE CABG + valve procedures Intraoperative TEE aids in the real-time assessment of heart valve function and pathology in those undergoing combination CABG and valve surgery.28-30 Isolated CABG procedures The use of intraoperative TEE in isolated CABG is less established but has been shown to aid in surgical and anesthetic decision-making as a tool for real-time assessment of hemodynamic status, regional wall motion, ventricular function, valve anatomy, and diastolic function.28-35 Pulmonary artery catheters High-risk surgery Highly selective use of pulmonary artery catheters for high-risk patients (ie, older, with congestive heart failure, pulmonary hypertension, or previous multiple valve procedures) may be safe and may potentially aid in the surveillance and treatment of hemodynamic instability.36-38 Low-risk surgery The use of pulmonary artery catheters in lowrisk or clinically stable patients is discouraged because the practice is associated with increased interventions that incur greater health care expense without associated improvement in morbidity or mortality rates.38-40 CNS monitoring Cerebral oxygen saturation Intraoperative monitoring of cerebral oxygen saturation (ie, near-infrared spectroscopy) to detect cerebral hypoperfusion has been shown to guide anesthetic decision-making and may prevent postoperative neurocognitive dysfunction.41-47 Processed electroencephalogram Routine use of intraoperative monitoring of processed electroencephalogram (ie, bispectral index) has yielded inconsistent results with respect to the prevention of recall, determination of depth of anesthesia, or improvement in rate of recovery after cardiac surgery.48-51 CABG indicates coronary artery bypass graft; CNS, central nervous system; and TEE, transesophageal echocardiography.

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