Surgical strategies for anatomically high-risk CABG scenarios

Introduction

Coronary artery bypass grafting (CABG) is one of the most performed cardiac surgeries with more than 160,000 cases completed in 2023 in the United States (1). With the advent of multiarterial grafting, minimally invasive approaches, and with sicker patients who have advanced, complex pathologies, CABG is still a very demanding procedure requiring advanced technical skills (2,3). Previous studies have discussed high-risk CABG, but mainly addressed physiological comorbidities, such as advanced age, diabetes, left ventricular dysfunction, and renal failure (4-6). However, in our review we shed light on another side of high-risk CABG, which is anatomically high-risk CABG (Table 1). We define anatomical high-risk CABG as CABG in which the surgeon faces patient-specific anatomical constraints and challenges that require complex preoperative planning and advanced surgical techniques to overcome to minimize risk and improve outcomes. We focus on select clinical scenarios, including porcelain aorta, poor targets and conduits, redo CABG, spontaneous coronary artery dissection (SCAD), and coronary aneurysms.

Hostile/porcelain aorta

Porcelain aorta is a structural aortic wall disease characterized by extensive, near circumferential or circumferential calcification of the intima or media of the ascending aorta or aortic arch with possibility of extension into the descending aorta (7). It most commonly occurs as a manifestation of advanced atherosclerosis, although it also can result from chronic aortitis or radiation heart disease. The aortic wall is impenetrable and highly friable, posing difficulties in aortic cannulation, aortic clamping, and aortotomy and proximal aorto-coronary bypass anastomosis. Porcelain aorta carries an increased risk of aortic tear and dissection (8) along with calcium particle and or athero-embolic stroke due to aortic manipulation during surgery (9).

The diagnosis of porcelain aorta is often made preoperatively using imaging modalities. Non-contrast computed tomography provides high sensitivity for detecting circumferential calcification, but transesophageal echocardiography (TEE) and chest radiography may also reveal characteristic findings, particularly in patients with unexplained embolic events or when planning cardiac surgery. The use of contrast enables detection of soft atheromas that may be associated with calcification. TEE is especially valuable for identifying mobile atheromatous plaques and superimposed thrombi, which are associated with a higher risk of embolic complications, including stroke and peripheral embolization.

Intraoperative epiaortic ultrasound provides real-time, high-resolution imaging of the ascending aorta to identify the presence, location, and severity of atherosclerotic plaque and calcification. Epiaortic ultrasound offers high spatial resolution and avoids the blind spots and artifacts inherent to TEE, particularly in the mid- and distal ascending aorta, and is markedly more sensitive than TEE and manual palpation (10,11). Epiaortic ultrasound enables surgeons to modify operative strategies—such as selecting alternative cannulation or cross-clamp sites, employing “no-touch” techniques, or avoiding aortic manipulation altogether. Several surgical alternatives have been proposed to avoid manipulation for porcelain aorta, including a no-touch technique basing all inflow from in-situ grafts with or without cardiopulmonary bypass or deep hypothermic circulatory arrest CABG with or without ascending aortic replacement.

Peripheral cannulation is often utilized if there are not suitable central cannulation options. Axillary artery is considered superior in terms of safety and clinical outcomes compared to ascending aorta and femoral artery (12,13). Alternatively brachiocephalic (innominate) artery cannulation has emerged as a noninferior alternative to axillary artery (14). Femoral artery cannulation, although technically feasible, is associated with higher risks of retrograde embolization and neurologic complications, particularly in patients with extensive atherosclerotic disease, and is generally reserved for situations where axillary or innominate access is not possible (13).

Intraluminal balloon endoclamping, in the absence of luminal atheroma, ascending aorta endarterectomy, patch aortoplasty, or strategic placement of proximal anastomotic site may be used in patients with less extensive disease of the ascending aorta (7,15).

Poor conduits and targets

Poor conduit quality and poor coronary target vessels are major challenges in CABG and have significant implications for both short- and long-term outcomes (Table 2). Poor conduit quality—such as saphenous vein grafts with varicosities or sclerosis, or arterial conduits with atherosclerosis or inadequate flow—leads to higher rates of graft failure due to thrombosis, intimal hyperplasia, and accelerated atherosclerosis (16).

In cases with poor quality saphenous vein grafts or previously harvested greater saphenous vein, arterial grafts constitute a valid option that is now widely regarded as superior to saphenous vein grafts for initial placement (17). Either a radial artery or right internal thoracic artery (RITA) can be used to supplement a left internal thoracic artery (LITA) to left anterior descending artery (18). Optimal long-term survival with bilateral internal thoracic artery (BITA) grafting is achieved by bypassing all important targets, defined as an artery reaching more than 75% toward the apex (19,20). Based on a recent study showing excellent RITA patency rates that are independent of inflow source, our strategy is to use any conduit configuration that allows arterial grafts to reach all important target coronaries targets (21). Gastroepiploic artery use is another option particularly in reoperations involving right coronary artery territory bypass.

When lesser saphenous vein use is necessary, we have used an internal thoracic artery (ITA) sternal lift system to elevate and position the leg to allow for endoscopic harvesting by a single operator (Figure 1) (22). A combination of arterial and venous grafts may be necessary to achieve complete revascularization (Video 1).

Figure 1 Endoscopic harvest of the lesser saphenous vein using a retractor system adapted to suspend the patient’s lower leg. This figure was reused with the permission of Yang et al. (22) that appears in Current Opinions of Cardiology, a Wolters Kluwer publication, and has been requested from Copyright Clearance Center.

Poor coronary targets—characterized by small vessel diameter, diffuse disease, heavy calcification, or prior extensive stenting “metal jacket”—are technically challenging to graft and are associated with lower graft patency and higher perioperative complication rates (23-25). Small-caliber vessels (<1.5 mm) and those with severe atherosclerosis are less likely to provide durable revascularization (26). However, large observational studies have shown that incomplete revascularization, which often results from not grafting small or diseased targets, is associated with higher major adverse cardiac events and worse outcomes after CABG compared to complete revascularization (26,27). Therefore, the decision to graft poor targets must balance the technical feasibility and the risk of incomplete revascularization, which is a strong predictor of adverse outcomes.

Endarterectomy, sequential grafting with bridging of lesions, and a long arteriotomy that traverses one or more stenotic lesions with a long-patch anastomosis are strategies that are used to address diffusely diseased targets. Coronary endarterectomy is used in diffuse atherosclerosis and absence of a suitable distal target (28). While associated with higher perioperative risk, contemporary series demonstrate acceptable morbidity and mortality in select patients, and it remains a valuable option for achieving complete revascularization in complex coronary disease (29-31).

In-stent restenosis is one of the leading cases of re-stenting which can lead to “metal jacket” coronary artery, referring to a coronary with long, overlapping stents, and often extending ≥60 mm, typically in the left anterior descending artery (32,33). CABG in metal jacket cases is challenging, and requires advanced surgical expertise involving a stent removal and endarterectomy with on-lay LITA patch or a vein patch to which LITA is anastomosed. The latter is advised in small caliber, friable or short LITA. In cases of diseased but not totally occluded metal jackets, a distal bypass beyond the stents may be an acceptable and less complex option.

Coronary angiography is the gold standard for identifying poor coronary artery targets, providing direct visualization of vessel diameter, diffuse disease, heavy calcification, and prior stenting, but it has limitations in assessing vessel wall characteristics (34,35). Coronary computed tomography angiography is particularly useful to further characterize coronary targets, especially when there is uncertainty about whether a target is too small or just underfilled, and to identify suitable landing soft spots for the distal anastomosis.

Quality control is paramount when dealing with challenging targets. Intraoperative transit time flowmetry and epicardial ultrasonography are widely used to assess graft patency and flow intraoperatively (35,36). Transit time flowmetry provides real-time quantitative data on graft flow and pulsatility index, helping to identify technical errors or poor runoff, which are more common with small or diseased targets. High-resolution epicardial ultrasound can visualize the anastomosis and detect technical issues, especially in challenging targets (5).

Redo-CABG

Redo-CABG is associated with a higher risk than primary CABG, with increased incidence of low cardiac output syndrome and perioperative complications (22). A major challenge in redo-CABG is availability of conduits. Ultrasound vein mapping of the lower extremities is a valuable tool for assessing the size and quality of any remaining saphenous vein suitable for grafting (22). When the greater saphenous vein is unavailable, the lesser saphenous vein can serve as an alternative and may be harvested endoscopically using a table-mounted mammary retractor. Additionally, ultrasound imaging of the radial arteries helps determine their viability for use without risking hand ischemia. If available, RITA should be considered because its use in reoperations after prior LITA harvest does not increase the risk of deep sternal wound infection, even in diabetic patients (37). In cases of limited conduit availability, composite grafting techniques such as Y, T, or I configurations can extend graft reach. Whenever possible, maximizing ITA inflow to ischemic myocardium should be prioritized, as it is associated with improved survival. Techniques like recycling LITA—defined as salvaging and re-using LITA again whether as inflow for a composite graft (such as a Y-graft) or reimplanted distally onto the same or a different coronary vessel—or using short vein grafts to bridge focal (Figure 2) or anastomotic lesions have also proven effective (38). If the LITA is redundant and can be safely mobilized, it may be recycled and redirected to a new target, with short- and mid-term patency (39).

Figure 2 Short saphenous vein used as a bridge when conduits are insufficient. This figure was reused with the permission of Yang et al. (22) that appears in Current Opinions of Cardiology, a Wolters Kluwer publication, and has been requested from Copyright Clearance Center.

Sternal re-entry can be hazardous in cases where there is adherence of vital cardiovascular structures including patent conduit to the posterior table of the sternum or the chest wall. Patent BITAs are particularly complex and RITAs crossing the midline present a specific risk of injury that needs to planned for prior to primary CABG (40). Along with sternal re-entry, meticulous mediastinal dissection is warranted, which helps to prevent injury to ITAs as well as assists in finding targets. Injury to patent ITA grafts during reoperation can result in catastrophic myocardial ischemia and injury.

Preoperative CTA imaging is essential to delineate graft anatomical risk stratification and plan the safest approach (41) with metal clips on ITA branches. Intraoperatively, strategies include careful sternal re-entry through cutting the sternal wires and keeping them in place until the sternum is divided, careful caudal-to-cranial dissection of structures off the posterior sternal table, use of alternative cannulation sites (femoral or axillary artery), and, when necessary, planned transection and re-anastomosis of ITAs (40). Patent in situ ITAs cannot deliver cardioplegia, and should ideally be controlled and occluded while administering cardioplegia. When antegrade cardioplegia down the native vessels and grafts off the aorta is not expected to be adequate, retrograde cardioplegia is vital, particularly when a large area of myocardium is exclusively perfused by the ITAs. Retrograde cardioplegia can be done directly and reliably through opening the right atrium and administered through the coronary sinus. Injuries to ITA can be prevented with judicious ITA positioning away from contact with the sternum or chest wall at the time of primary CABG. Nevertheless, if injury does occur, repair techniques including interposition vein grafts or translocation as a Y-graft may be required. Atraumatic occlusion of patent ITAs during aortic clamping and systemic cooling are used to optimize myocardial protection.

Targets can be more challenging to find in a redo scenario. Old grafts can be a guide to new targets, and surgeon experience is crucial to achieve complete revascularization and optimize outcomes.

Despite all of these risks, outcomes in experienced centers have improved and can approach those of primary CABG, especially with meticulous preoperative planning and imaging to guide sternal re-entry, mediastinal dissection, and target identification strategies (22). Redo-CABG with multiarterial grafting has lower in-hospital and long-term mortality and similar major morbidity to single arterial grafting (42).

SCAD

SCAD is defined as a nonatherosclerotic, nontraumatic, and noniatrogenic separation of the coronary artery wall, resulting in the formation of an intramural hematoma or intimal tear, which compresses the true lumen and causes myocardial ischemia or infarction (43,44). SCAD is a significant cause of acute coronary syndrome and myocardial infarction, particularly in women under 50 years of age, accounting for up to 4% of acute coronary syndrome cases and a higher percentage of young women (90% of SCAD cases) (45). SCAD presents most commonly as chest pain, but can also present with ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, ventricular arrhythmias, or sudden cardiac death. Therefore, high suspicion of SCAD is needed in young-aged women without evident risk factors who present with ischemic signs and symptoms, thus necessitating confirmation by imaging. Coronary angiography is the first-line diagnostic tool with characteristic angiographic patterns (46). Intracoronary imaging with intravascular ultrasound or optical coherence tomography can confirm the diagnosis, especially in ambiguous cases, but carries a risk of iatrogenic extension.

SCAD management is primarily conservative since most dissections heal spontaneously, and surgical intervention might increase the associated risks. Prognosis is generally favorable, with low in-hospital and long-term mortality. However, recurrence rates of SCAD and major adverse cardiac events are significant, necessitating long-term follow-up (45,46). Surgical intervention is typically reserved for cases of ongoing ischemia, hemodynamic instability, left main involvement, or refractory arrhythmias (47). Both arterial and venous conduits have been used, but due to the high rate of late graft failure from competitive flow after native vessel healing, the use of vein grafts is often preferred to preserve arterial conduits for future use (44,46). Moreover, an extended arteriotomy is sometimes mandated when there is extensive extension of dissection and distal vessel involvement to allow en bloc excision of the thrombus and dissection flap (48). That does not only add to the complexity of the surgery, but also requires a long anastomosis to incorporate the extended arteriotomy. Conduit selection is guided by the high likelihood of native vessel healing and the risk of competitive flow, which can lead to late graft failure. Competitive flow from recanalized native vessels is a major concern in SCAD, making vein grafts more appropriate for non-left anterior descending artery targets where the risk of graft occlusion is higher and their patency is less critical in these regions (44). Arterial conduits, especially the left internal mammary artery, are recommended for the left anterior descending territory due to their superior long-term patency and survival benefit.

Coronary aneurysms and fistulas

Coronary artery aneurysms (CAAs) are defined as focal dilatations of a coronary artery segment exceeding 1.5 times the diameter of an adjacent normal segment, with a reported prevalence of 0.02% to 0.35% in angiographic series, and are most commonly associated with atherosclerosis in adults and Kawasaki disease in children (49,50). CAAs may be saccular or fusiform in morphology and can arise from a variety of etiologies, including atherosclerosis, inflammatory conditions (such as vasculitis), congenital anomalies, or iatrogenic injury (51).

Patients with CAAs can present with a range of symptoms including angina, acute coronary syndrome, myocardial infarction, and arrhythmias, but most commonly CAAs are asymptomatic and discovered incidentally during coronary angiography or other cardiac imaging (52). Noninvasive modalities, such as coronary computed tomography angiography and cardiac magnetic resonance imaging, are increasingly used for further anatomical delineation, assessment of mural thrombus, and evaluation of adjacent cardiac structures. In 0.2% to 1.2% of cases, CAA is associated with a fistula [congenital coronary artery fistula (CCAF)] (53).

Management of CAAs is individualized and there are no randomized controlled trials or universally accepted guidelines for their management. For small, asymptomatic aneurysms without significant stenosis or limited fistulas, conservative management with risk factor modification and antiplatelet therapy is generally favored because these lesions have a relatively benign course (54). For large or giant aneurysms (greater than 4 times the reference vessel diameter or 10 mm in diameter) (55,56), we prefer surgical intervention even in the absence of symptoms, although recommendation of lifelong follow-up and treatment with anticoagulants (57) may be appropriate especially in poor operative candidates. Surgery is also recommended for asymptomatic CCAF with significant left-to-right shunt with Qp;Qs >1.5 (58,59). Significant shunting increases right-side volume and pressure load, and results in RV dilatation and eventual failure. Transcatheter closure (using coils, vascular plugs, or covered stents) is favored for suitable anatomy, with similar procedural success and reintervention rates in CCAFs with or without aneurysm, although post-closure thrombosis is more common in the aneurysm group (60). However, in the event of thrombosis, device failure, or contraindication, or with a distal fistula diameter >10 mm, surgical intervention is recommended.

Furthermore, revascularization is needed for CAAs associated with significant obstructive coronary disease. Surgical repair is recommended when the aneurysm itself is deemed at high risk for complications, such as rapid expansion, evidence of impending rupture, or recurrent embolization (49). Percutaneous coronary intervention with drug-eluting stents, coil embolization, or Amplatzer™ (Abbot Structural Heart, Santa Clara, CA, USA) device implantation has been described, but is technically challenging and associated with risks, including distal embolization, no-reflow, stent malposition, and vessel rupture (49,54).

In this scenario, surgical techniques have reliable outcomes (61) and the most common approach is to open the CAA, suture its afferent and efferent vessels, and finish with bypass grafting if needed (54). Other techniques include aneurysm resection, ligation with distal bypass, and marsupialization with interposition graft.

For fistula, on the other hand, a limited, fistula repair-only approach, with opening the distal segment of the aneurysm, closure of the fistula at its communicating orifice, or internal closure from the receiving chamber—carries the risk of residual shunting, thrombosis, ischemia, or continued aneurysmal dilation and rupture. However, recently, the Pettersson technique has been proposed, achieving the expected benefits of surgical correction of CCAF without any noted previous complications (59). Pettersson technique is done through opening the entire aneurysm sac, ligation of the fistula coronary branches, and revascularization from within using arterial conduits or saphenous veins. The interposition conduit bypasses all side-branch orifices that accept a 1 mm probe (smaller branches are ligated) with an end-to-side anastomosis. The procedure bears a resemblance to an open thoracoabdominal aortic aneurysm approach. In a recent case (Figure 3), Awad et al. repaired a CAA with a distal fistula between the posterior descending artery and the great coronary vein. A cul-de-sac of a normal-sized proximal right coronary artery gave off small conus and right ventricular outflow tract branches. The remaining right coronary artery was replaced with an interposition vein graft that was based off the aorta and bypassed 8 branches and the fistula was ligated (Figure 3) (59).

Figure 3 The aneurysmal RCA was incised lengthwise and laid open (①). A saphenous vein harvested endoscopically from the leg was laid inside the RCA and attached sequentially with end-to-side anastomoses (②) to all significant side branches, creating 8 bypasses (2 on the back of the heart are not visible). A cul-de-sac was created in the healthy section of RCA coming off the aorta (③) to secure adequate blood supply to early RCA branches. Vein graft was taken off the aorta (④) and this proximal anastomosis became new blood inflow to the remaining right side of the heart. The fistula was also ligated (⑤). RCA, right coronary artery.

Conclusions

Anatomically high-risk CABG cases include, but are not limited to, porcelain aorta, poor conduits and targets, redo-CABG, SCAD, and coronary aneurysms—all of which present significant technical challenges. The beacon for success in managing these cases lies in meticulous preparation: detailed preoperative imaging, robust myocardial protection, expeditious and complete revascularization, and, above all, the ability to adapt and improvise when necessary.

Acknowledgments

The authors acknowledge Cleveland Clinic Communications Manager Ingrid Sprague, MBA, for her editorial assistance.

Footnote

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1563/prf

Funding: This study was supported by the Sheikh Hamdan Bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery (to F.G.B.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1563/coif). F.G.B. reports funding from Sheikh Hamdan bin Rashid Al Maktoum Distinguished Chair in Thoracic and Cardiovascular Surgery. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.Written informed consent was obtained from the patient for the publication of the accompanying video.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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