Arterial grafting for coronary artery revascularisation
Professor Alistair Royse, a cardiothoracic surgeon, undertakes research into coronary bypass surgery. He was one of the pioneers for the utilization of the radial artery as a conduit in coronary artery surgery. The radial artery has been used at the Royal Melbourne Hospital since 1994. This included the use of complex novel grafting strategies including sequential grafting methods and the joining of arteries together (composite or Y grafts) which led to technique and outcome publications during 1998-2002. This innovation led to rapid and significant change to clinical practice in the mid 1990s, the use of the radial artery grafts rising from 5% to 85% in 1997, and total arterial revascularisation increasing from 5% to 68%. These figures have remained constant since 1997. By comparison, in the United States and Europe, total arterial revascularization is only 5 - 6%, and use of the radial artery only about 4%.
Late clinical follow up has found that there is a survival advantage to total arterial revascularisation as well as use of the radial artery and a complex reconstruction (Y graft).
Frequent symptom-driven and other preoperative angiograms performed at a minimum of more than 10 years postoperative reveal no progressive atherosclerosis over time as is present with saphenous vein grafts. Some prospective research-driven angiograms reveal no arterial conduit atherosclerosis more than 10 years postoperative. Indeed, all arterial grafts appear to behave similarly and appear to be resistant to late atherosclerosis formation. There are three ongoing studies on patient's at least 10 years postoperative:
- Patients who received all three conduits (a mammary artery, radial artery and saphenous vein), assessed by angiography;
- Clinically indicated angiography where a radial artery has been used and
- Survival and quality of life data on coronary bypass patients.
Other related research
Following on from being the only Australian to be listed as an associate investigator on the successful Canadian TRICS-III grant application (CAN $3.3 million) to the Canadian Institutes of Health Research (CIHR - the equivalent of NHMRC), Alistair was the CIA of the successful 2014 NHMRC project grant for the Australian arm of the TRICS-III trial, being funded $1.4 million. This study randomises patients who undergo cardiac surgery with the bypass pump into two monitoring groups. The patients haemoglobin is monitored and the transfusion trigger activated when the haemoglobin falls. The study will determine the haemoglobin for transfusion post cardiac surgery. Alistair is a member of the TRICS III steering committee.
Alistair was the Australian lead investigator for the steroids in cardiac surgery (SIRS) trial which closed in 2014. The results were published in the Lancet in 2015.
Alistair is the lead Australian investigator for the following research:
Canadian-led left atrial occlusion trial (LAAOS-III) and is a member of the Canadian steering committee.
Phase 2 study into EVARREST, a new topical haemostatic agent manufactured by Johnson & Johnson, conducted as an international multicentre trial which closed in December 2015.
Perceval sutureless valve registry (SURE-AVR).
Alistair is the Principal Investigator at the Royal Melbourne Hospital for the following research:
COMPASS trial randomizing rivaroxaban in a prospective randomized double-blind trial led by Richard Whitlock of McMaster University and the Population Research Health Institute (PHRI) in Canada, examining neurological and cardiovascular events in cardiac surgery and cardiology patients.
CLIP a frozen platelet prospective blinded study due to commence in May 2016.
PERSIST-AVR a prospective randomised study into a new sutureless aortic valve vs conventional valve replacement due to commence in late 2016.
ITACS a randomised, double-blind, controlled phase 4 trial to compare the efficacy safety and cost-effectivness of preoperative IV iron with placebo in patients with anaemia before elective cardiac surgery.
Professor Alistair Royse, Co-director, Ultrasound Education Group -
Professor Colin Royse, Co-director, Ultrasound Education Group
Dr David Canty, Senior Lecturer and Director of Simulation, Ultrasound Education Group
Royal Melbourne Hospital
Western General Hospital
- Whitlock, R.; Healey, J.; Vincent, J.; Brady, K.; Teoh, K.; Royse, A.; Shah, P.; Guo, Y.; Alings, M.; Folkeringa, R. J.; Paparella, D.; Colli, A.; Meyer, S. R.; Legare, J. F.; Lamontagne, F.; Reents, W.; Boning, A.; Connolly, S. Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III Ann Cardiothorac Surg (2014) 3 1 45-54 PMID: 24516797 RGMS ID P12892405. Most relevant to this NHMRC application.
- Royse CF, Canty DJ, Faris J, Haji DL, Veltman M, Royse A. Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg (2012) 115 5 1007 - 1208 RGMS ID P01483152. A review of physician-performed ultrasound a change that is likely to change clinical practice by providing all physicians with immediate and better diagnostic accuracy.
- Canty, D; Kim, M; Royse, C; Andrews, D; Bottrell, S; Royse, A The Impact of Routine Norepinephrine Infusion on Hemodilution and Blood Transfusion in Cardiac Surgery Anesthe Clinic Res (2013) 4 8 1-5 RGMS ID P12285184. This paper illustrate a new approach to blood management by adopting a preventative approach – minimising haemodilution and thus need for blood transfusion.
- Haji, D. L.; Royse, A.; Royse, C. F. Review article: Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia Emerg Med Australas (2013) 25 1 4-12 PMID: 23379446 RGMS ID P12285183. The benefits of point of care ultrasound are widely applicable.
- Royse, A. G.; Royse, C. F. Epiaortic ultrasound assessment of the aorta in cardiac surgery Best Pract Res Clin Anaesthesiol (2009) 23 3 335-41 RGMS ID P10490719. Follow up technique paper describing the methods of performing intraoperative ultrasound examination of the aorta prior to manipulation to prevent cerebral atheroembolism. This technique has been performed several thousand times.
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