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Ann Thorac Surg 1997;63:1797-1799
© 1997 The Society of Thoracic Surgeons

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How To Do It

Facilitated Exposure of the Internal Mammary Artery in Minimally Invasive Direct-Vision CABG

Heart Lung Institute, Department of Cardiothoracic Surgery, Utrecht University Hospital, Utrecht, the Netherlands

Accepted for publication December 20, 1996.

	Abstract

Top Footnotes Abstract Introduction Technique Comment Addendum References

 
A method is described to facilitate harvesting of the mammary artery in minimally invasive direct-vision coronary artery bypass grafting using a 10-cm anterior thoracotomy. Hoisting of the anterior thoracic wall with a modified retractor allows good exposure. Harvesting the mammary artery without the use of endoscopic tools was successful in all 10 cases.

	Introduction

Top Footnotes Abstract Introduction Technique Comment Addendum References

 
See also page 1799.

Safe harvesting of the left internal mammary artery (IMA) in minimally invasive direct-vision coronary artery bypass grafting without cardiopulmonary bypass (MIDCABG) can be difficult due to the limited exposure, ie, mediastinotomy or small anterior thoracotomy. In particular, dissection up to the level of the first intercostal branch may result in damage to the left IMA, due to the progressively smaller working angle in the horizontal and vertical planes. By improving the angles in both planes with a more lateral approach and hoisting up the anterior thoracic wall using a modified mammary artery retractor, a wider tunnel for exposure is obtained. This facilitates dissection of the left IMA.

	Technique

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The patient is in a supine position and is intubated with a double-lumen endotracheal tube for selective ventilation of the right lung. In addition to general anesthesia, epidural anesthesia is added routinely for pain relief.

A 10-cm anterior thoracotomy is performed in the fourth intercostal space under the nipple. The pleura is opened. A small Finochietto spreader is placed. The distal left IMA is approached laterally. The left IMA is harvested in a skeletonized fashion by first clipping the side branch in the fourth intercostal space. No rib cartilage is removed. The internal mammary artery retractor (Rultract; Pemco Inc, Mentor, OH) is mounted on the opposite side of the incision: one hook is placed under the sternal table and the other hook under the craniad rib (Fig 1). The retractor has been modified: the hooks' teeth have been flattened to conform to the cartilage contour and one of the hooks is smaller. The retractor hoists the anterior thoracic wall (Fig 2). The endothoracic fascia is split and dissection of the left IMA is advanced rostrally by clipping off the side branch in the third intercostal space. Then the third rib is hoisted separately by passing a heavy braided suture with a large needle from the outside, under this rib cartilage, and again to outside and attaching it also to the retractor for hoisting (see Fig 2).

View larger version (149K): [in this window] [in a new window]   Fig 1. . View from the left side of the patient from caudally. The modified internal mammary artery retractor is mounted on the right operating table rail and hoists the anterior thoracic wall. Note the special button with groove for wrapping the suture loop (arrow).

View larger version (135K): [in this window] [in a new window]   Fig 2. . Detailed view through the 10-cm thoracotomy wound without hoisting (A) and with hoisting (B). The displacement of the dotted line indicates the elevation of the third rib by the heavy braided suture loop (arrow) attached to the retractor. Note the modified hook (two teeth) and the skeletonized internal mammary artery (tip of the forceps).

Harvesting is facilitated greatly by an intrathoracic light source in addition to the headlight. In this respect illuminated cautery (Clearcut; Medtronic, Grand Rapids, MN) proved to be very effective.

Dissection of the distal left IMA is extended to the fifth interspace.

	Comment

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Safe harvesting of the left IMA is essential in MIDCABG, especially because no other conduit is available. Two features are important: proper illumination and approach of the IMA under a slight angle to obtain a better view for adequate clipping and severing of the side branches. With respect to this angle, we moved from a paramedian approach (in the first 6 patients) to somewhat more lateral in the horizontal plane, ie, under the nipple. Using this approach and with the elevation of the anterior thoracic wall, the dissection of the left IMA becomes safe. In our experience, removal of cartilage is not necessary.

Several techniques have been developed for better exposure of the proximal left IMA: cutting of the cartilage of one or two ribs craniad to the thoracotomy level [1], vertical mediastinotomy [2], and the use of specially designed spreaders. We found that elevation of the anterior thoracic wall by the modified retractor, aided by suture loops around one or two ribs, is more stable and effective than manual hoisting. The technique is less traumatic: the cartilages could be left intact. Moreover, it leaves no scars.

Atraumatic dissection of the IMA in a skeletonized fashion takes approximately 60 minutes (range, 45 to 75 minutes). Harvesting of this artery is still time consuming even though time has shortened with increased experience.

So far, we have used this technique successfully in 10 left IMA preparations in MIDCABG. The left IMA was used as a single graft to the left anterior descending artery in 6 patients and as a sequential graft to the diagonal branch and left anterior descending artery in 4 patients. No damage to the left IMA occurred in these 10 patients, whereas one IMA had to be repaired in the preceding experience with 6 MIDCABG patients in whom we did not use this technique. The left IMA was anastomosed on the beating heart using a suction device (the Utrecht "octopus" method) for regional cardiac wall immobilization [3]. All grafts were found to be patent intraoperatively by a hand-held Doppler velocity probe.

With respect to analgesia, epidural anesthesia contributed considerably to the patient's comfort, compared with the patients in whom this type of anesthesia was contraindicated because of enhanced bleeding tendency. All patients were extubated within 2 to 3 hours after the operation. Postoperative length of hospital stay ranged from 3 to 6 days (average, 4.4 days). Angiography at 6-month follow-up showed all 10 grafts to be patent, and 13 of 14 anastomoses were patent. Occasionally, a minor patent IMA side branch was seen proximally near the origin, which seems to be of minor importance [4]. All 10 patients are free of angina. Reinterventions did not occur.

In our experience the modified retractor greatly facilitates exposure of the anterior thoracic wall for safe harvesting of the IMA. This modification obviates the need for endoscopic harvesting in MIDCABG. Theoretically, the system may be used for the right IMA too.

	Addendum

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Recently we found this technique was not useful in patients with an extremely rigid thoracic cage (1 of 31 patients).

	Footnotes

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Address reprint requests to Dr Jansen, Heart Lung Institute, Department of Cardiothoracic Surgery, Rm E03.406, Utrecht University Hospital, PO Box 85500, 3508 GA Utrecht, the Netherlands.

	References

Top Footnotes Abstract Introduction Technique Comment Addendum References

 

1. Robinson MC, Gross DR, Zeman W, Stedje-Larsen E. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Cardiac Surg 1995;10:529–36.[Medline]
2. Stanbridge RDeL, Symons GV, Banwell PE. Minimal-access surgery for coronary artery revascularisation. Lancet 1995;346:837.[Medline]
3. Borst C, Jansen EWL, Tulleken CAF, et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol 1996;27:1356–64.[Abstract]
4. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Erik W. L. Jansen Paul F. Gründeman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jansen, E. W. L. Articles by Bredée, J. J. Search for Related Content PubMed PubMed Citation Articles by Jansen, E. W. L. Articles by Bredée, J. J. Related Collections Related Article