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Ann Thorac Surg 1999;68:131-136
© 1999 The Society of Thoracic Surgeons

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Original Articles

Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle

^a Department of Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan

Address reprint requests to Dr Watanabe, Department of Surgery, Toyama Medical and Pharmaceutical University, Sugitani 2630, Toyama, Japan, 930-0194

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality rate. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting without cardiopulmonary bypass for total revascularization of the left ventricle using multiple arterial grafts.

Methods. Limited lateral thoracotomy was performed in the fourth or fifth intercostal spaces, exposing the left anterior descending coronary artery and left circumflex coronary artery. Two or three arterial grafts were harvested. Revascularization of the left anterior descending coronary artery and the left circumflex coronary artery were performed in 20 patients without cardiopulmonary bypass through the limited lateral thoracotomy using complex performed arterial grafts. In 4 patients, triple- and quadruple-vessel grafting was performed.

Results. The mean coronary cross-clamp time was 14.5 ± 4.0 minutes for the left anterior descending coronary artery and 16.8 ± 5.1 minutes for the left circumflex coronary artery. No early deaths or postoperative complications occurred. There were no late deaths or angina during the mean follow-up of 7.0 months (range, 2 to 22 months). Postoperative coronary angiography demonstrated widely patent grafts in all patients.

Conclusions. Minimally invasive approach through a limited thoracotomy in multiple coronary artery bypass graftings are technically feasible and may be an alternative approach in the complete revascularization of the left ventricle. Mechanical immobilization of the coronary artery enhances early graft patency and is an essential part of this procedure.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery (LAD) through a minithoracotomy has been shown to produce excellent results with a very low mortality rate [1]. However, this procedure is limited by the fact that only the LAD and diagonal branches are accessible through an anterior left minithoracotomy. We have modified the procedure to revascularize the left circumflex coronary artery (LCX) and have developed a new technique using small lateral thoracotomies, which allows us to perform minimally invasive direct coronary artery bypass grafting (MIDCABG) in the setting of multivessel disease. In this report we describe our experience with complete left ventricular revascularization using multiple arterial grafts with special emphasis on the surgical techniques that are required.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From May 1996 to May 1998, 20 patients underwent complete revascularization of the left ventricle using complex performed arterial conduits. These patients represent 29% (20 of 70 patients) of MIDCABG and 16% of total coronary artery bypass grafting operations (124 patients) during this time period. The clinical characteristics of the patients are summarized in Table 1.

Internal thoracic artery and right gastroepiploic artery harvesting technique
Intraarterial digital subtraction angiography of the both ITAs were performed preoperatively in all patients to minimize the time required for graft selection. The ITA was harvested thoracoscopically. A standard 10-mm thoracoscope was placed through a trocar in the fifth intercostal space in the anterior axillary line. Additional ports were placed in the third and fifth intercostal spaces for the introduction of endoscopic instruments. The left ITA was harvested with a Harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) as a pedicle using video imaging guidance. In 1 patient, bilateral ITAs were harvested thoracoscopically. Technical details of this procedure are as follows. After the completion of the bilateral ITA harvesting, the endoscopic forceps were inserted through the right side trocars to grasp the right ITA pedicle. The right ITA was divided and diverted across the anterior mediastinum extrapericardially by manipulation through the left minithoracotomy. The left ITA was also divided and coronary anastomoses were performed.

The right gastroepiploic artery (RGEA) graft was approached through a small (5 cm) upper laparotomy incision. The gastrocolic ligament was freed by division of the omental branches using a Harmonic scalpel. A gauze soaked with a papaverine solution was wrapped around the pedicle.

Graft selection and composite graft construction
In patients with left main coronary artery disease or multivessel disease with a large LAD, we revascularized the left ventricle with two in situ arterial grafts. The combination of the grafts and the coronary arteries depends on the length of each grafts and the site of previous myocardial infarction. Cross-over technique (Fig 1A) is a suitable combination when the right ITA has sufficient length to reach the LAD. The second combination is the left ITA to the LAD and the RGEA to LCX as shown in Figure 1C. Especially in a patient with anterior myocardial infarction with scar formation, we use the left ITA to the LCX and the RGEA to the LAD (Fig 1D).

View larger version (93K): [in this window] [in a new window]   Fig 1. Four variations of the operative technique for complete revascularization of the left ventricle using arterial grafts. (A) The crossover technique, which includes the left internal thoracic artery (LITA) to the left circumflex coronary artery (CX) and right internal thoracic artery (RITA) to left anterior descending artery (LAD) anastomoses. (B) Composite Y-branched graft using the left internal thoracic artery and radial artery (RA) or inferior epigastric artery (IEA). (C) Composite lengthened graft using the right gastroepiploic artery (RGEA) to the radial artery or inferior epigastric artery. (D) left internal thoracic artery and right gastroepiploic artery grafts to the left anterior descending artery and left circumflex coronary artery. (ICS = intercostal space; RCA = right coronary artery.)

End-to-side anastomosis
The posterior fascia of the pedicled ITA was incised longitudinally (8 mm) at the level of the third intercostal space. The free graft was anastomosed with 8-0 suture (Ethicon Inc, Somerville, NJ). The donor conduit was unclamped proximally after the free graft was clamped and the site of the anastomosis inspected. The RA or IEA were used to revascularize the LCX.

End-to-end anastomosis
If there was a relatively short RGEA graft, the RA or IEA was anastomosed to the RGEA in an end-to-end fashion, creating a lengthened composite graft. The RGEA composite graft was passed through the fibrous portion of the diaphragm and positioned behind the heart. All of the anastomoses between the conduits were performed under heparinization and before the coronary anastomosis. The coronary anastomosis was performed with 7-0 or 8-0 sutures.

Thirty-four conduits were used in the 20 patients: 20 left ITAs, 1 right ITA, 10 RGEAs, 12 RAs, and 6 IEAs. Of the 18 free arterial conduits, 15 were anastomosed to the left ITA and 3 to the RGEA. Figure 1 illustrates the different arrangements of the conduits in the composite grafts.

The position of the skin incision and the distance between the LCX and the body surface was determined by computed tomographic scanning (Fig 2). To minimize the skin incision, preoperative skin marking was performed in the operating room according to computed tomography scanning. The chest was opened through a left anterior small lateral thoracotomy from just above the LAD to the LCX as shown in Figure 2 in the fourth or fifth intercostal space. The ribs were not resected and the pericardium was incised vertically parallel to the sternum. This technique facilitated exposure of the left free wall of the heart. The LAD and LCX were then inspected. After systemic heparinization (1.5 mg/kg), the harvested ITAs and RGEA were divided distally using clips. The ends of the grafts were brought through the incision and prepared for grafting. The ITAs were injected with 3 mL of papaverine solution. The coronary anastomoses were completed using 8-0 propylene sutures without cardiopulmonary bypass after ischemic preconditioning. Immobilization and coronary occlusion during the distal anastomosis was performed using a MIDCAB doughnut by Takahashi and colleagues [2] (Fig 3).

View larger version (101K): [in this window] [in a new window]   Fig 2. Computed tomographic scanning of the chest demonstrating the measured distance between the left circumflex coronary artery (LCX) and body surface and the position of the skin incision (*). (LAD = left anterior descending artery.)

View larger version (109K): [in this window] [in a new window]   Fig 3. Regional cardiac wall immobilization using a mechanical coronary artery stabilizer (MIDCABG doughnuts), during the anastomosis of the left circumflex coronary artery (LCX). (Inset) Close-up the anastomotic site of the left circumflex coronary artery. (LITA = left internal thoracic artery.)

	Results

Top Abstract Introduction Patients and methods Results Comment References

The mean harvest time was 53 ± 29 minutes for the ITA. The number of distal anastomoses ranged from two to four with an average of 2.4 ± 0.7 anastomoses per patient. The mean coronary clamp time was 14.5 ± 4.0 minutes for the LAD and 16.8 ± 5.1 minutes for the LCX. There was no significant difference in the clamp time for the two anastomoses.

No early deaths or postoperative complications occurred in any of the 20 patients. There was no need for inotropic or mechanical support. The mean operative time was 4.6 ± 1.5 hours. No blood transfusions were required. No increase in the serum creatine kinase isozyme was detected in any of the patients after operation. The median stay in the intensive care unit was 1 day. The length of the typical postoperative hospital stay ranged from 7 days to 2 weeks.

Early angiographic controls were performed between the fifth and tenth postoperative days. The results are summarized in Table 2. The representative angiographic features of these performed conduits are shown in Figures 4 through 6. No late deaths occurred during the average follow-up period of 7.0 ± 5.6 months (range, 2 to 22 months). Furthermore, there was no evidence of recurrent angina.

View larger version (141K): [in this window] [in a new window]   Fig 4. Angiographic demonstration of the anastomosis between the left internal thoracic artery (LITA) and left anterior descending coronary artery (LAD), which is Y-branched with the radial artery (RA) to left circumflex coronary artery (LCX) anastomosis.

View larger version (152K): [in this window] [in a new window]   Fig 5. Angiographic demonstration of the anastomosis between the left internal thoracic artery (LITA) and left circumflex coronary artery (LCX) (right) and the right internal thoracic artery (RITA) and left anterior descending coronary artery (LAD) (left).

View larger version (192K): [in this window] [in a new window]   Fig 6. Angiographic demonstration of the anastomosis between the right gastroepiploic artery (RGEA) lengthened with inferior epigastric artery (IEA) and left circumflex coronary artery (LCX).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

In the present study we have demonstrated the technical feasibility of LCX and LAD grafting through a small left thoracotomy. In our experience, patients with multivessel disease can undergo complete revascularization of the left ventricle using composite arterial grafts. Furthermore, use of this procedure yields favorable early and mid-term results. This technique allows the surgeon to increase the extent of arterial myocardial revascularization safely and to overcome the technical problems associated with LCX grafting.

However, some technical expertise is required to expose the LCX through a small incision. To minimize the size of the skin incision, we routinely used preoperative chest computed tomography scanning to determine the location of the skin incision. In addition, preoperative determination of the location of the LCX is important. The distance between the body surface and the LCX vessel influences the technical difficulty of LCX grafting. In our series, the distance between the body surface and the LCX was less than 8 cm. Grafting the LCX is relatively more difficult than the LAD because of the deeper location of the anastomotic site. However, there was no significant difference in the coronary clamp time between LAD and LCX grafting in our series.

Direct ITA harvesting through a small incision is more difficult using our approach because the location of the skin incision is more lateral than that for the standard anterior MIDCABG procedure. Therefore, thoracoscopic ITA dissection is necessary. This thoracoscopic technique provides the following advantages and broadens the indications for the multiple MIDCABG procedure. First, if the ITA is short or tortuous in its proximal portion, thoracoscopic dissection straightens the ITA so that it can reach the distal coronary anastomotic site. Second, the potential for the "steal" phenomenon [5] through patent proximal major side branches of the ITA is avoided. Third, the right ITA can be harvested thoracoscopically, LAD and CX could be revascularized using in situ both ITAs through one incision. We call this technique the "cross-over MIDCABG."

No technical problems are encountered with left ITA-to-LAD grafting. However, the graft selection for LCX grafting is more difficult. Connecting the free RA-to-IEA end-to-side to the left ITA (the composite technique) may be preferable, especially in multiple MIDCABG procedures. In addition, this procedure may be suitable in dealing with a diseased aortic wall, absence of an adequate graft, and a relatively short ITA graft. Calafiore and colleagues [6] hypothesized that improved patency rates might be achieved using a composite graft because of lower shear forces and a more natural rate of pressure development than that obtained in proximal connections to the ascending aorta.

In patients with left main coronary artery disease or multivessel disease with a large LAD, we believe that it is safer to revascularize the two most important regions of the left ventricle with two in situ arterial grafts. Grafting the pedicled right ITA across the midline to revascularize the LAD and using the left ITA to revascularize the LCX is an optimal procedure. However, in patients with a relatively short right ITA graft, the RGEA graft may be used as an alternative arterial conduit. When used as a pedicled graft, the patency rate of the RGEA is similar to that for the left ITA—at least 5 years [7, 8]. In 3 patients, we performed both left ITA-to-LAD and RGEA-to-RA-to-LCX graftings. We chose the RGEA-to-RA composite graft because of the large caliber of the graft at its distal anastomosis. Angiography demonstrated that all of the grafts were patent. In particular, there was no caliber mismatch at the site of anastomosis between the RGEA and the IEA or RA.

The distal coronary anastomoses were created using a mechanical coronary stabilizer with 8-0 running polypropylene suture. For the LAD grafting, a commercially available compression-type mechanical immobilization platform will be useful [9, 10]. However, for the LCX grafting, a compression-type mechanical immobilization platform is unable to stabilize the anastomotic site because the left ventricular free wall is like a perpendicular cliff from the surgeon’s point of view. Therefore, we use the suction-type stabilizer described by Takahashi and associates [2]. The instrument can make the operative field both motionless and bloodless without distal snaring of the coronary artery. The instrument uses negative pressure to attach to the heart at the anastomotic site. Using this device, approximately 15 minutes of displacement of the heart is tolerated hemodynamically. Using this method, off-pump grafting of the LCX is feasible through a small lateral thoracotomy. In our experience, the suction-type stabilizer greatly facilitates anastomosis of the LCX as well as the LAD.

In conclusion, the multiple MIDCABG through a small left thoracotomy represents a novel way of approaching both the LAD and the LCX in patients with multivessel disease. Although technically demanding, the procedure provides many options to the surgeon attempting to accomplish complete arterial revascularization of the left ventricle. The early and mid-term results are encouraging. If long-term follow-up studies confirm good patency rates, this procedure may become the standard procedure for coronary artery bypass grafting.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Calafiore A.M., 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;61:1658-1665.[Abstract/Free Full Text]
2. Takahashi M., Yamamoto S., Tabata S. Immobilized instrument for minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 1997;114:680-682.[Free Full Text]
3. Benetti F.J., Ballester C., Sani G., Doonstra P., Grandjean J. Video assisted coronary bypass surgery. J Cardiac Surg 1995;10:620-625.[Medline]
4. Sabramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1997;64:1648-1655.[Abstract/Free Full Text]
5. Spanos P.K., Bisbos A.D., Arditis I.I. Treatment of internal thoracic artery steal syndrome with supraclavicular approach. J Thorac Cardiovasc Surg 1998;115:464-465.[Free Full Text]
6. Calafiore A.M., Di Giammarco G., Luciani N., et al. Composite arterial conduits for a wider arterial myocardial revascularization. Ann Thorac Surg 1994;58:185-190.[Abstract/Free Full Text]
7. Suma H., Wanibuchi Y., Terada Y., et al. The right gastroepiploic artery graft. Clinical and angiographic mid-term results in 200 patients. J Thorac Cardiovasc Surg 1993;105:615-623.[Abstract]
8. Suma H., Amano A., Fukuda S., et al. Gastroepiploic artery graft for anterior descending coronary artery bypass. Ann Thorac Surg 1994;57:925-927.[Abstract/Free Full Text]
9. Subramanian V.A. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997;63:S58-S71.
10. Boonstra P.W., Grandjean J.G., Mariani M.A. Local immobilization of the left anterior descending artery for minimally invasive coronary bypass grafting. Ann Thorac Surg 1997;63:S76-S78.

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