Ann Thorac Surg 1998;65:1774-1776
© 1998 The Society of Thoracic Surgeons
Case Reports
Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting
Vassilios Gulielmos, MDa,
Markus Dangel, MDa,
Stephan Schüler, MDa
a Cardiovascular Institute, University Hospital Dresden, Dresden, Germany
Accepted for publication December 18, 1997.
Address reprint requests to Dr Schüler, Cardiovascular Institute, University Hospital Dresden, Fetscherstr 76, D-01307 Dresden, Germany
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Abstract
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We report about a 71-year-old man with coronary artery double-vessel disease who received minimally invasive coronary artery bypass grafting through a 9-cm left lateral chest incision in the third intercostal space. Both mammary arteries were harvested either directly (left internal mammary artery) or thoracoscopically (right internal mammary artery) and anastomosed to the left anterior descending artery and the circumflex artery through this single left lateral chest incision. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.
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Introduction
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Minimally invasive surgical techniques for the treatment of coronary artery disease have been recently developed to reduce surgical trauma and sternotomy-related complications. Total arterial revascularization using the left internal mammary artery (LIMA) for the left anterior descending artery and the right internal mammary artery for other coronary arteries promises better patency of the coronary arteries grafted [1, 2] but can result in a higher rate of sternotomy-related problems [3, 4].
Harvesting of both mammary arteries is not feasible with most minimally invasive surgical techniques. Therefore a surgical technique based on an experimental model was applied not only to allow minimally invasive surgical treatment of patients with multivessel disease, but also to allow harvesting of both mammary arteries through one small left lateral chest incision without additional chest incisions.
A 71-year-old man suffering from double-vessel coronary artery disease and having an amputation of his right leg claimed to have dyspnea during physical exercise. Because of recurrent angina pectoris episodes the patient was admitted to the hospital twice, where electrocardiograms revealed temporarily ST-segment elevation without any electrocardiographic or enzymatic signs of cardiac infarction. Coronary angiography revealed normal left ventricular ejection fraction (0.74) and coronary double-vessel disease with significant lesions of the left anterior descending artery and the large intermediate branch. To avoid surgical trauma to the remaining leg, we decided to use both internal mammary arteries.
The patient was placed in the supine position with a rubber cushion under his left shoulder to elevate the left half of the body. Through a 9-cm left lateral parasternal chest incision in the third intercostal space, the third and fourth ribs were divided from the sternum at their sternal edge, but not removed. The LIMA was harvested under direct vision. After systemic heparinization the LIMA was dissected distally. The right internal mammary artery was completely dissected thoracoscopically through the left-sided chest incision (Fig 1) without use of any additional chest ports. After take-down, the proximal end was attached with an end-to-side technique to the LIMA as a T graft. The blood flow through both grafts was controlled. The arterial return cannula was introduced into the ascending aorta via the same limited chest incision. In parallel the right groin was dissected and venous drainage for cardiopulmonary bypass was accomplished via the femoral vein. External cross-clamping was performed and cardioplegic arrest was achieved by administration of cold crystalloid cardioplegia via the ascending aorta. The same line was used for aortic root venting. During cardioplegic arrest the heart was rotated to the right and the intermediate branch was exposed. The distal end of the right internal mammary artery was anastomosed to the intermediate branch with an end-to-side technique. After left rotation of the heart, the left anterior descending artery was exposed and the distal end of the LIMA was anastomosed in a standard fashion to the left anterior descending artery. After antegrade deairing the aortic clamp was released. During reperfusion, routinely used epicardial pacemaker wires were placed on the right atrium and on the right ventricle. The patient was weaned from cardiopulmonary bypass, the aortic and the femoral vein cannulas were removed, and heparin was antagonized with protamine. Two chest tubes were left in place. The third and fourth ribs were attached to the sternum with steel wires, and both wounds were closed in layers (Fig 2).
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Fig 1. The right internal mammary artery was harvested through the left lateral chest incision transmediastinally with endoscopical instruments without any additional chest ports.
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Fig 2. The closed chest incision after a minimally invasive operation for multivessel coronary artery disease.
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The patient was weaned from cardiopulmonary bypass without inotropic support, in sinus rhythm, and without any signs of ischemia. Harvesting time of both internal mammary arteries was 134 minutes, total time of the operation was 317 minutes, cardiopulmonary bypass time was 75 minutes, and intensive care unit stay was 1 day. Cardiac enzymes monitored 6 and 12 hours as well as 2 and 5 days after operation gave no sign of cardiac infarction. The blood loss was 500 mL. Chest tubes were removed on the second postoperative day, and the patient was discharged from the hospital on the fifth postoperative day and is alive and well 24 weeks postoperatively.
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Comment
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Total arterial revascularization is an accepted strategy and has been proposed for improvement of the long-term results of coronary artery bypass grafting [1, 2]. Coronary flow reserve seems to be enough using arterial T graft [5]. Recently a variety of minimally invasive procedures have been described focusing on the treatment of coronary artery single-vessel disease [6–9]. In case of use of cardiopulmonary bypass the term "minimally invasive approach" seems to be more appropriate to some than "minimally invasive operation." However, these techniques used only the LIMA. The present case report demonstrates a minimally invasive surgical technique allowing the harvesting of both internal mammary arteries through a small (9 cm) lateral chest incision using a combined direct and thoracoscopic technique of dissection. In addition, the presented technique allows the treatment of multivessel coronary artery disease with cardiopulmonary bypass and cardioplegic arrest. Furthermore, cannulation of the femoral vessels can be avoided, thus avoiding additional vascular complications. The present technique seems to be a safe technique, and further expansion toward more extensive arterial grafting using the radial artery may be the next step. The proposed technique presents an alternative for a patient group with high risk of development of sternotomy-related complications in addition to lack of great saphenous vein grafts for any reasons. Even though the required technical abilities for this procedure are rather high, the benefit is the safety provided and the patients’ early convalescence without the fear of sternotomy-related complications.
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References
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- Grandjean J.G., Boonstra P.W., den Heyer P., Ebels T.J. Revascularization of the myocardium for three vessel disease using all 3 arterial grafts including the right gastroepiploic artery. J Thorac Cardiovasc Surg 1996;112:935-942.[Abstract/Free Full Text]
- Antona C, Zanobini M, Pompilio G, et al. Total arterial myocardial revascularization. Presented at the International Workshop on Arterial Conduits for Myocardial Revascularization, Rome, Italy, Nov 16–18, 1994.
- Tarelli G, Maugeri R, Pedretti R, Musazzi A, Respighi E. Single IMA versus double IMA. Early postoperative complications in 1,391 patients. Presented at the International Workshop on Arterial Conduits for Myocardial Revascularization, Rome, Italy, Nov 16–18, 1994.
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Abstract
Introduction
