Stroke risk after on-pump minimally invasive multivessel coronary artery bypass grafting with right axillary artery cannulation and preoperative computed tomography angiography

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OBJECTIVES: Stroke remains a major concern in on-pump minimally invasive coronary artery bypass grafting, particularly when peripheral arterial cannulation and aortic manipulation are required in patients with systemic atherosclerosis. This study evaluated stroke outcomes after total coronary revascularization via left anterior thoracotomy with preoperative computed tomography angiography and right axillary artery cannulation. METHODS: A total of 800 consecutive patients undergoing isolated non-emergent multivessel minimally invasive coronary artery bypass grafting were analysed. All procedures were performed on cardiopulmonary bypass with right axillary artery cannulation, transthoracic aortic cross-clamping, cardioplegic arrest, cardiac slinging manoeuvres and side-bite clamping for proximal anastomoses. Of these, 85.4% were male; median age was 67.0 years (IQR 13.0) and median EuroSCORE II was 2.0 (IQR 2.1). All patients underwent preoperative computed tomography angiography. Stroke events were analysed by timing, distribution and presumed mechanism. RESULTS: The overall in-hospital rate of major adverse cardiac and cerebrovascular events was 1.9%. In-hospital mortality was 1.0%, myocardial infarction 0.4%, repeat revascularization 0.6% and stroke 0.6%. All strokes were ischaemic. Two strokes (0.25%) occurred within 72 hours and were considered procedure-related, whereas three (0.37%) occurred after 72 hours and were associated with postoperative atrial fibrillation or advanced intracranial atherosclerosis. CONCLUSIONS: In patients undergoing minimally invasive on-pump multivessel CABG after preoperative CTA confirmed suitable anatomy for transthoracic clamping and planned aortic manipulation, a standardized TCRAT strategy with right axillary artery cannulation was associated with a low rate of clinically apparent in-hospital stroke. These findings support the feasibility and clinical rationale of this approach in routine practice, while comparative studies are required to define its independent effect on stroke prevention.

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