Ann Thorac Surg 1998;65:1331-1334
© 1998 The Society of Thoracic Surgeons
Minimally Invasive Surgical Technique for the Treatment of Multivessel Coronary Artery Disease
Vassilios Gulielmos, MDa,
Michael Knaut, MDa,
Florian M. Wagner, MDa,
Stephan Schüler, MDa
a Cardiovascular Institute, University Hospital Dresden, Dresden, Germany
Accepted for publication December 23, 1997.
Address reprint requests to Dr Schüler, Cardiovascular Institute, University Hospital Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
 |
Abstract
|
|---|
Background. To avoid sternotomy-related complications after cardiac operations, we developed a minimally invasive surgical technique for the treatment of multivessel coronary artery disease.
Methods. From November 1996 to May 1997, 39 patients (age range, 50 to 78 years) with coronary artery disease were treated with the use of this technique. Through a small (6- to 9-cm) left lateral chest incision in the third intercostal space, the left internal mammary artery was harvested directly. With the use of cardiopulmonary bypass and cardioplegic arrest in all patients except 1, the left internal mammary artery was anastomosed to the left anterior descending artery. In addition, vein grafts and other arterial conduits were used for revascularization of the other coronary arteries.
Results. There were no intraoperative complications. All the patients survived the procedure and had an uneventful postoperative course. Wound complications occurred in 2 patients. The median (± standard error of the mean) hospital stay was 6 ± 1 days.
Conclusions. This technique combines minimally invasive surgical conditions with the safety standards of routine cardiac operations. With the use of this approach, even extensive coronary artery disease can be treated.
|
Introduction
|
|---|
The successful treatment of single-vessel coronary artery disease (CAD) using a minimally invasive surgical approach has been reported recently [1–4]. Our experience with this technique started with a Port-Access system (Heartport, Redwood City, CA) included such safety standards of cardiac operation as cardiopulmonary bypass and cardioplegic arrest. The technique was introduced successfully at our institution in March 1996. The results of our first series of 42 patients were very encouraging, but the technique was limited to patients with single-vessel disease [5, 6]. There was a significant risk of vascular complications with the use of femoral arterial cannulation and the endoaortic occlusion catheter. Further, Port-Access technology did not allow access to the ascending aorta for the attachment of proximal vein graft anastomoses. Therefore, another surgical technique was developed to avoid sternotomy-related complications [7–14], femoral arterial cannulation, and the use of the endoaortic occlusion catheter. In addition, it allowed the treatment of triple-vessel disease with the use of the left internal mammary artery (LIMA) and additional vein grafts and other arterial conduits when necessary.
|
Patients and methods
|
|---|
Patients
Between October 1996 and May 1997, this minimally invasive surgical technique was used in 39 consecutively treated patients. The patients ranged in age from 50 to 78 years (median, 66 years). There were 6 women and 33 men. The exclusion criteria for this procedure were obesity (ie, a body mass index of greater than 1.30) and impaired left ventricular function (ie, a left ventricular ejection fraction of less than 0.40). Patients with significant arteriosclerotic lesions of the aorta on ultrasonographic examination also were excluded.
Eight patients had single-vessel disease (stenosis of the left anterior descending artery [LAD] and the diagonal branch), 19 patients had double-vessel disease (including 6 with significant mainstem stenosis), 8 patients had stenosis of the LAD and the left circumflex artery, 1 patient had stenosis of the LAD and the intermediate branch of the left circumflex artery, and 4 patients had significant lesions of the LAD and the right coronary artery (Table 1). Twelve patients had triple-vessel disease.
Surgical technique
The patient was placed in the supine position with a rubber cushion under the left shoulder. A single-lumen airway tube was used for double-lung ventilation. A 6- to 9-cm skin incision was made at the level of the third intercostal space (Fig 1) and the sternal edges of the third and fourth ribs were divided but not removed. The intercostal muscles were divided further laterally underneath the skin to avoid postoperative pain caused by spreading of the intercostal nerves. Thus, an operative field measuring 6 by 5 cm was achieved. Even in women, the surgical gate provided no problems because the breast was pulled caudally using tapes.
With the use of a small wound retractor, the LIMA was harvested as a pedicle through the incision up to the first and down to the sixth ribs and then divided distally. Mediastinal fat was dissected, the pericardium was opened toward the ascending aorta, and stay sutures were placed between the pericardium and the wound soft tissue to retract the ascending aorta toward the chest incision. During harvest of the LIMA, saphenous vein segments also were harvested. The ascending aorta was dissected from the pulmonary trunk. After cannulation of the femoral vein and ascending aorta, cardiopulmonary bypass was begun. In 1 patient, the right atrium was cannulated using a two-stage cannula (Fig 2).
View larger version (149K):
[in this window]
[in a new window]
|
Fig 2. Through the chest incision, the central part of the heart can be reached and arterial cannulation (A) of the ascending aorta and venous cannulation (B) of the right atrium are feasible.
|
|
The ascending aorta was cross-clamped and cold antegrade crystalloid cardioplegia was delivered through a standard cardioplegic cannula. During cardioplegic arrest, aortic root venting was performed. Exposure of all coronary arteries was facilitated by rotating the heart 45 degrees for the right coronary artery and 60 degrees for the marginal branch of the left circumflex artery in all cases. An end-to-side anastomosis was performed between the vein graft and the coronary arteries in a standard fashion (Fig 3), followed by anastomosis of the LIMA to the LAD (Fig 4).
View larger version (164K):
[in this window]
[in a new window]
|
Fig 4. Left internal mammary artery bypass graft to the left anterior descending artery (A), vein graft to a diagonal branch of the left anterior descending artery (B), and vein graft to a marginal branch of the left circumflex artery (C).
|
|
In 1 patient, total arterial revascularization was performed using the left and right internal thoracic mammary arteries. The right internal mammary artery was harvested thoracoscopically through the left-sided chest incision. The LIMA was used as a conduit for the LAD and the right internal mammary artery was attached to the intermediate branch. The proximal end of the right internal mammary artery was anastomosed end-to-side as a "T-graft" to the LIMA (Fig 5).
View larger version (166K):
[in this window]
[in a new window]
|
Fig 5. In 1 patient, both internal mammary arteries were harvested. The left internal mammary artery was attached to the left anterior descending artery (A). The right internal mammary artery was attached end-to-side to the left internal mammary artery as a T graft (B). The right internal mammary artery was attached to the intermediate branch of the left circumflex artery (C).
|
|
After standard removal of air from the heart, the aortic cross-clamp was removed and the proximal ends of the vein grafts were attached end-to-side to the ascending aorta (Fig 6). After the placement of temporary pacemaker wires, the patient was weaned from cardiopulmonary bypass. The sternal edges of the third and fourth ribs were attached to the sternal border with two steel wires. The attachment of the ribs still left a certain gap between two ribs. To avoid future herniation, the two ribs were approximated further using a 1-mm polydioxanone suture. Two chest tubes were left in place and the chest incision was closed in layers (Fig 7).
View larger version (158K):
[in this window]
[in a new window]
|
Fig 6. The proximal ends of the vein grafts (A and B) were attached end-to-side to the ascending aorta.
|
|
View larger version (126K):
[in this window]
[in a new window]
|
Fig 7. The closed chest incision after minimally invasive operation for triple-vessel coronary artery disease.
|
|
|
Results
|
|---|
All patients survived the procedure and were weaned from cardiopulmonary bypass without inotropic support in sinus rhythm and with no signs of ischemia. Conversion to a median sternotomy was not necessary in any patient. A total of 39 LIMA anastomoses and 48 vein grafts were performed. The coronary vessels that were grafted are listed in Table 2.
In 1 patient, the LIMA was discovered to have severe arteriosclerotic lesions during harvesting and a vein graft had to be applied to the LAD. In another patient, the LIMA was used as a free graft to the LAD because of a severe stenotic lesion of the left subclavian artery.
Postoperative complications included delayed wound healing of the groin in 1 patient, wound infection of the chest incision in 1 patient, and a lymphatic fistula in 1 patient. The median (± standard error of the mean) postoperative hospital stay was 6 ± 1 days (Table 3). At 12 weeks’ follow-up, no patient had signs of ischemia on stress electrocardiography and only 1 patient had pain with exercise on pain assessment. All patients except the 1 with the wound infection were pleased with the cosmetic results of their operation.
View this table:
[in this window]
[in a new window]
|
Table 3. Intraoperative and Postoperative Data for 39 Patients Undergoing a Minimally Invasive Cardiac Surgical Techniquea
|
|
|
Comment
|
|---|
This surgical technique allows the complete treatment of multivessel CAD under minimally invasive surgical conditions with the use of current surgical standards such as cardiopulmonary bypass, cardioplegic arrest, use of the LIMA as a conduit for the LAD, and use of vein grafts or other arterial conduits for the revascularization of other coronary arteries. Harvesting of the LIMA is performed through the chest incision without the need for additional ports. This incision, made in the third intercostal space, also allows good access to the ascending aorta. Moving the chest incision from the fourth intercostal space to the third intercostal space enables access to the central part of the heart, allowing for cannulation of the ascending aorta, the application of cardioplegia, and volume unloading of the left ventricle. Furthermore, proximal vein grafts can be attached to the ascending aorta. Cardioplegic arrest allows complete access to all areas of the heart. In some cases, even cannulation of the right atrium using a two-stage cannula is possible. With this minimally invasive surgical technique, complete revascularization is feasible in patients with extensive coronary artery disease with the standards of safety of regular coronary artery bypass grafting and the ability to use the LIMA and other arterial conduits.
|
References
|
|---|
- Benetti F.J., Ballester C., Sani G., Boonstra P., Grandjean J. Video assisted coronary bypass surgery. J Card Surg 1995;10:620-625.[Medline]
- Acuff T.E., Landreneau R.J., Griffith B.P., Mack M.J. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135-137.[Abstract/Free Full Text]
- Calafiore A.M., De Giammarco G., Teodori G., et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
- Diegeler A., Falk V., Walther T., Mohr F.W. Minimally invasive coronary artery bypass surgery without extracorporeal circulation. N Engl J Med 1997;336:1454-1455.[Free Full Text]
- Reichenspurner H., Gulielmos V., Daniel W.G., Schueler S. Minimally invasive coronary artery bypass (CABS) with the safety of cardiopulmonary bypass and cardioplegic arrest. N Engl J Med 1997;336:67-68.[Free Full Text]
- Stevens J.H., Burdon T.A., Peters W.S., et al. Port-Access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
- Weinzweig N., Yetman R. Transposition of the greater omentum for recalcitrant median sternotomy wound infections. Ann Plast Surg 1995;43:471-477.
- Zacharias A., Habib R.H. Factors predisposing to median sternotomy complications. Deep vs superficial infection. Chest 1996;110:1173-1178.[Abstract/Free Full Text]
- Moore R., Follette D.M., Berkoff H.A. Poststernotomy fractures and pain management in open cardiac surgery. Chest 1994;106:1339-1342.[Abstract/Free Full Text]
- Casscells C.D., Lindsey R.W., Ebersole J., Li B. Ulnar neuropathy after median sternotomy. Clin Orthop 1993;291:259-263.
- Bryan A.J., Lamarra M., Angelini G.D., West R.R., Breckenridge I.M. Median sternotomy wound dehiscence: a retrospective case control study of risk factors and outcome. J R Coll Surg Edinb 1992;37:305-308.[Medline]
- Furnary A.P., Magovern J.A., Simpson K.A., Magovern G.J. Prolonged open sternotomy and delayed sternal closure after cardiac operations. Ann Thorac Surg 1992;54:233-239.[Abstract]
- Hanson M.R., Breuer A.C., Furlan A.J., et al. Mechanism and frequency of brachial plexus injury in open heart surgery: a prospective analysis. Ann Thorac Surg 1983;36:675-679.[Abstract]
- Merchant R.N., Brown W.F., Watson B.V. Peripheral nerve injuries in cardiac anesthesia. Can J Anaesth 1990;37:152.
This article has been cited by other articles:
|
|
|
|
 
J. F. Angle, A. H. Matsumoto, J. K. McGraw, D. J. Spinosa, K. D. Hagspiel, D. A. Leung, and C. G. Tribble
Percutaneous Angioplasty and Stenting of Left Subclavian Artery Stenosis in Patients with Left Internal Mammary-Coronary Bypass Grafts: Clinical Experience and Long-Term Follow-up
Vascular and Endovascular Surgery,
March 1, 2003;
37(2):
89 - 97.
[Abstract]
[PDF]
|
|
|
|
|
|
|
V. Gulielmos, M. Menschikowski, H.-M. Dill, M. Eller, S. Thiele, S. M. Tugtekin, W. Jaross, and S. Schueler
Interleukin-1, interleukin-6 and myocardial enzyme response after coronary artery bypass grafting - a prospective randomized comparison of the conventional and three minimally invasive surgical techniques
Eur. J. Cardiothorac. Surg.,
November 1, 2000;
18(5):
594 - 601.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. T. Cremer, T. Wittwer, A. Boning, M. B. Anssar, T. Kofidis, A. Mugge, and A. Haverich
Minimally invasive coronary artery revascularization on the beating heart
Ann. Thorac. Surg.,
June 1, 2000;
69(6):
1787 - 1791.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. S. Bedi, A. Suri, M. S. Kalkat, B. S. Sengar, V. Mahajan, R. Chawla, and V. P. Sharma
Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion
Ann. Thorac. Surg.,
January 1, 2000;
69(1):
156 - 164.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Gulielmos, M. Eller, S. Thiele, H.-M. Dill, T. Jost, S. M. Tugtekin, and S. Schueler
Influence of median sternotomy on the psychosomatic outcome in coronary artery single-vessel bypass grafting
Eur. J. Cardiothorac. Surg.,
November 1, 1999;
16(suppl_2):
S34 - S38.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. Wimmer-Greinecker, G. Matheis, S. Dogan, T. Aybek, S. Mierdl, P. Kessler, and A. Moritz
Patient selection for Port-AccessTM multi vessel revascularization
Eur. J. Cardiothorac. Surg.,
November 1, 1999;
16(suppl_2):
S43 - S47.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Reichenspurner, D. Boehm, C. Detter, W. Schiller, and B. Reichart
Economic evaluation of different minimally invasive procedures for the treatment of coronary artery disease
Eur. J. Cardiothorac. Surg.,
November 1, 1999;
16(suppl_2):
S76 - S79.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
V. Gulielmos, M. Brandt, M. Knaut, R. Cichon, F. M. Wagner, U. Kappert, and S. Schuler
The Dresden approach for complete multivessel revascularization
Ann. Thorac. Surg.,
October 1, 1999;
68(4):
1502 - 1505.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Cremer, A. Mugge, T. Wittwer, A. Boening, P. Kim, T. Kofidis, H. Drexler, and A. Haverich
Early angiographic results after revascularization by minimally invasive direct coronary artery bypass (MIDCAB)
Eur. J. Cardiothorac. Surg.,
April 1, 1999;
15(4):
383 - 388.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
