HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) 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): Antonio M. Calafiore Gianni D. Angelini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lloyd, C. T. Articles by Angelini, G. D. Search for Related Content PubMed PubMed Citation Articles by Lloyd, C. T. Articles by Angelini, G. D. Related Collections Related Article

Ann Thorac Surg 1999;68:908-911
© 1999 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization

^a Department of Anaesthetics and Cardiovascular Radiology, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
^b Departments of Cardiac Surgery and Cardiology, University of Chieti, Chieti, Italy

Address reprint requests to Prof Angelini, Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW UK
e-mail: g.d.angelini{at}bristol.ac.uk

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The minimal access surgical technique of a left anterior small thoracotomy (LAST) for coronary artery bypass grafting is now well established. This procedure however, does not allow multivessel revascularization. We present our early experience of an integrated approach using LAST and percutaneous transluminal coronary angioplasty (PTCA), either staged or simultaneous.

Methods. Eighteen patients (14 men and 4 women), mean age 63 (range 35–87 years) were treated. Four patients underwent simultaneous LAST and PTCA revascularization. The remaining 14 patients were first treated with the LAST procedure, followed 1–3 days later by angioplasty. Angiographic assessment was carried out before PTCA and at 6 months after.

Results. The 14 patients who underwent the staged procedure all had patent left internal mammary artery/ left anterior descending coronary artery grafts. Angioplasty was performed on 21 vessels (10 stented) with good early angiographic results. All patients were extubated early, mean intensive care stay was 14.7 + 9.4 hours, mean hospital stay was 5 + 1.5 days. All patients were symptom free at 18 months follow-up.

Conclusions. Staged LAST and angioplasty is a safe and effective approach suitable for patients in whom there are contraindications to the use of extracorporeal circulation. The simultaneous approach is limited by the risk of bleeding associated with the use of anticoagulation when coronary stenting is required.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Minimally invasive direct coronary artery bypass (MIDCAB) surgery is becoming widely accepted as an alternative method for revascularization in single vessel coronary artery disease [1]. The most common approach is the left anterior small thoracotomy (LAST) incision for access to the left anterior descending (LAD) coronary artery [2]. The patients most likely to benefit are those in whom coexistent pathology increases the risks associated with cardiopulmonary bypass (CPB) [3–5], young patients in whom progression of the disease is likely, elderly patients, and where a midline sternotomy itself carries a possible risk (as in redo operations, for example) [6–9]. The Achilles heel of the technique, however, is that we can still access only a single vessel. Given the fact that most patients who require intervention have multivessel disease, only a limited group of patients with single vessel disease may be offered this procedure, or patients with multivessel disease are incompletely revascularized surgically. The combined use of the LAST with percutaneous transluminal coronary angioplasty (PTCA), otherwise known as the "hybrid procedure," was initially reported by our group [10] and subsequently by Friedrich and associates [11] as a useful alternative to conventional surgery in patients with multivessel disease. The long-term results of combining these 2 procedures have yet to be fully evaluated. We present the preliminary results of our initial series.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between February 1996 and July 1996 18 patients (9 in Bristol, UK and 9 in Chieti, Italy) underwent combined LAST and angioplasty for multivessel disease. The group comprised 14 men (77.8%) and 4 women (22.2%) whose age ranged between 35 and 87 (mean, 63 years). Fourteen of the patients had good left ventricular (LV) function (assessed angiographically as an ejection fraction > 50%), 3 patients had moderate (35–49%), and 1 poor (< 35%) LV function. The preoperative demographic data is summarized in Table 1. Ethical approval was granted by both institutions and informed consent was obtained from all patients.

Angioplasty indications
Candidates were limited to a maximum of 2 diseased vessels other than the LAD artery. Extensive coronary involvement, distal lesions, chronic totally occluded arteries, and tortuous vessels were considered contraindications to attempting angioplasty. Complex lesions were considered suitable if possible deployment of a stent appeared appropriate. Techniques such as directional atherectomy or excimer-laser angioplasty were not attempted. Four patients underwent simultaneous LAST and PTCA. This required that the LAST procedure be performed in the cardiac catheter suite followed by the angioplasty during the same general anaesthetic. Fourteen (78%) patients had elective delay of the PTCA after a minimum of 24 hours recovery following the LAST procedure.

Surgical technique
The method for the LAST procedure has been described in detail previously [12]. Briefly, a left anterior small thoracotomy incision was made through the fourth or fifth intercostal space for access to the LAD anastomosis site. Dissection and mobilization of the LIMA was carried out with or without the aid of a thoracoscope and injected intraluminally with dilute papaverine to prevent vasoconstriction. The proximal and distal LAD was snared with 4/0 Prolene (Ethicon, Somerville, NJ) and the anastomosis constructed with continuous 7/0–8/0 Prolene. Esmolol, a short acting intravenous ß-blocker was used to pharmacologically slow the heart (50 to 75 beats per minute) during the anastomosis. Diastolic flow in the LIMA graft was demonstrated at the end of the anastomosis by standard transthoracic continuous-wave Doppler ultrasonography to confirm patency. All patients received aspirin 300 mg every 4 hours postoperatively and were commenced on subcutaneous heparin 5000 iu every 12 hours.

During both simultaneous and delayed procedures a cardiopulmonary bypass machine was on standby (dry) throughout the operative period.

PTCA technique
Standard access for PTCA was achieved via cannulation of the femoral artery with the insertion of a hemostatic sheath and the use of a 6- or 8-French guiding catheter. Initial diagnostic angiography was performed with the objective of assessing the quality of the LIMA to LAD graft and to confirm the anatomy of the lesion(s) for angioplasty. Angioplasty was performed using 6- or 8-French guiding catheters. In all cases the lesions were cannulated with a 0.014-inch steerable guidewire followed by balloon dilatation with or without additional stenting. Stent deployment depended upon the operator’s assessment of the lesion following initial balloon dilatation. Heparinization was used throughout the procedure with the ACT maintained over 300 seconds. All patients received antiplatelet therapy following the procedure. Patients who had angioplasty only received aspirin 300 mg orally postoperatively whereas additional therapy included Ticlopidine 250 mg orally.

Follow-up
Nine patients had elective follow up angiography at 5 to 8 months. Ethical approval could not be obtained for asymptomatic patients at one of the institutions (Bristol, U.K.) for elective reangiography. Long term functional outcome was assessed at 18 months.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The clinical outcome of the 18 patients is summarized in Table 2. In total, 21 vessels underwent angioplasty (3 patients had angioplasty to 2 vessels). The distribution is summarized in Table 3. Ten (55.5%) patients had stent implantation; 2 of these had simultaneous procedures.

One patient was returned to the operating room following problems with angioplasty and stenting. The patient, a 53-year-old male, had simultaneous LAST and stenting of an obtuse marginal (OM) branch of the circumflex artery. Postoperative recovery in the intensive care unit was complicated by the development of posterior ischemic changes on electrocardiogram tracings. Reangiography showed a thrombosed stent. It was believed that the cause of the thrombosis was inadequate anticoagulation. Additional thrombolysis was considered inappropriate in view of the recent surgery and it was therefore elected to return the patient to the operating theater. A single venous graft to the OM branch on CPB was performed as an uncomplicated procedure.

One patient developed atrial fibrillation, which responded to pharmacological treatment. One patient required transfusion of a single unit of packed red cells. No patient received fresh frozen plasma or platelets.

Late complications included the development of a deep vein thrombosis in the calf of one patient; this condition responded to intravenous heparin infusion followed by oral anticoagulation with warfarin. A second patient was readmitted 4 weeks after surgery with a suspected pulmonary embolus on ventilation/perfusion scan which, again, responded to intravenous heparin and oral anticoagulation with warfarin.

Mean primary hospital stay was 5 ± 1.5 days (Range 3 to 7 days). There were no other postoperative complications and there were no deaths.

Angiography of the LIMA to LAD graft at the time of angioplasty showed patency of all grafts. Late follow-up angiography was electively performed in 9 of the 18 patients. Mean time of angiography was 6 months (range 5 to 8 months). All 9 showed patency of the LIMA to LAD graft and absence of restenosis of the angioplasty vessel, including those that had been stented. Patients were followed-up to monitor a functional status at 18 months following the procedure and all but 1 (grade I compared to grade IV preoperatively) remain symptom free and on no antianginal treatment.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The reason for the increase in MIDCAB surgery is two-fold. Firstly, it is patient driven, aimed at a faster recovery time, shorter hospital stay, and an earlier return to work. Secondly, it is surgically driven to avoid the complications associated with CPB and sternotomy. Paralleled to the growth of interest in MIDCAB grafting is the growing use of interventional cardiovascular procedures [13]. The increase in the use of PTCA has been accompanied by the introduction of newer techniques, particularly stenting. However, although angioplasty allows multiple vessel revascularization, it is only indicated on appropriate and accessible lesions. Restenosis still remains a problem and overall PTCA compares unfavorably with bypass grafting with respect to use of antianginal medication and requirement for further revascularization [14]. The use of stenting has also seen a dramatic rise over recent years with technical refinements allowing better deployment of the stent and improving restenosis rates [15]. Indeed, stenting has reduced this restenosis rate in the early period by 25% to 30% and moreover reduces the need for reintervention by 50% [16].

Both bypass grafting and PTCA have their limitations and advantages, but rather than seeing them as mutually exclusive there may be a role in particular patients for their combined use.

The decision to perform both procedures either during the same anesthesia or with a delay period depends on a number of factors. Having initially performed the procedures simultaneously, we have opted for the delayed approach. We have always operated before angioplasty but clearly there may be a role for patients who have had only partially successful angioplasty to undergo minimally invasive surgery later.

The advantages of the simultaneous approach involve only a single operative time for the patient and complete revascularization at the one visit. The graft and anastomosis can be assessed at the time of operation and discomfort for the patient during angioplasty minimized. The first disadvantage with this approach is the necessity to operate in the unfamiliar environment of the catheter suite and claustrophobic atmosphere from excess equipment. The second disadvantage is the inability to use stents following angioplasty with the inherent risks of anticoagulant induced hemorrhage from both the anastomotic site and surgical incision. These risks are weighed against the risk of acute stent thrombosis, which unfortunately occurred in 1 of the patients in whom a stent was used. Both aspirin, which inhibits the formation of Thromboxane A₂, and Ticlopidine, which interferes with platelet aggregation by irreversibly blocking the binding of fibrinogen to the glycoprotein IIb/IIIa receptor, are used to prevent this acute thrombosis and are used routinely in our departments following stent employment. Other agents such as Abciximab, the monoclonal antibody 7E3 which binds to the IIb/IIIa receptor, are also being evaluated but still suffer the limitation of hemorrhagic complications [17]. Newer heparin-bonded stents may also provide an alternative for the use of stenting during MIDCAB procedures, without the need for systemic anticoagulation. The results as suggested from the pilot phase of the Benestent II study [18], which showed no acute thrombosis in the series of 203 patients, are encouraging.

The advantage with a delayed procedure is the ability to provide both interventions under ideal circumstances. Hemostasis is not a problem, narrowed lesions can be stented, and the angiogram performed at that time allows an opportunity to visualize the graft in the postoperative period. The disadvantage is the recovery of the patient with potentially incomplete revascularization before proceeding to angioplasty after a few days and the prolongation of hospital stay/recovery time. However, with a mean stay of 5 ± 1.5 days, this group compares well with conventional bypass surgery.

The optimum time period before reintervention is patient-dependent, but we prefer to allow a minimum of 24–48 hours before angioplasty if the procedure is to be staged. By this time the risk of bleeding and therefore potential hemorrhagic complications should be minimal.

We regard this combined approach as a safe viable alternative for the treatment of high-risk patients with multivessel disease, which allows early complete revascularization with minimal postoperative morbidity. The limitations with this report, however, remains the relatively low number of patients and the problems associated with eligibility of patients for a prospective randomized trial. In our institution this has been brought about in part by the increase in off-bypass (beating heart) surgery with midline sternotomy. This approach also allows access to multiple coronary arteries for revascularization. The benefits of avoiding CPB are still maintained and hence we are now operating on all eligible patients in this manner. Although access to the LAD and RCA territory on the beating heart is usually uncomplicated, access to the circumflex artery territory, and in particular proximal lesions can prove difficult. In this circumstance, combined angioplasty as a delayed procedure may provide an alternative to the use of CPB. Whether there will remain a place for the hybrid procedure in conjunction with minimal access surgery or in conjunction with off-bypass surgery is still too early to predict and further work is needed to establish this for the future.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Borst C., Santamore W., Smedira N., Bredee J. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;63:S1-S5.
2. Calafiore A., Angelini G. Left anterior small thoracotomy (LAST) for coronary artery revascularisation. Lancet 1996;347:263-264.[Medline]
3. Pathi V., Ramphal P., Berg G., MacArthur K. Emergency bypass without bypass. Ann Thorac Surg 1996;62:877-878.[Abstract/Free Full Text]
4. Moshkovitz Y., Sternik L., Paz Y., et al. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular dysfunction. Ann Thorac Surg 1997;63:S44-S47.
5. Benetti F., Mariani M., Ballester C. Direct coronary surgery without cardiopulmonary bypass in acute myocardial infarction. J Cardiovasc Surg 1996;37:391-395.[Medline]
6. Mohr R., Moshkovitz Y., Gurevitch J., Benetti F. Reoperative coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1997;63:S40-S43.
7. Benetti F., Ballester C., Sani G., Boonstra P., Grandjean J. Video assisted coronary bypass surgery. J Cardiac Surg 1995;10:620-625.[Medline]
8. Fanning W., Kakos G., Williams T. Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486-489.[Abstract]
9. Grandjean J., Mariani M., Ebels T. Coronary reoperation via small laparotomy using right gastroepiploic artery without CPB. Ann Thorac Surg 1996;61:1853-1855.[Abstract/Free Full Text]
10. Angelini G., Wilde P., Salerno T., Bosco G., Calafiore A. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularization. Lancet 1996;347:757-758.[Medline]
11. Friedrich G., Bonatti J., Dapunt O. Preliminary experience with minimally invasive coronary artery bypass surgery combined with coronary angioplasty. N Engl J Med 1997;336:1454-1455.[Free Full Text]
12. Calafiore A., Di Giammarco G., Teodori G., Bosco G., D’Annunzio E., Barsotti A. 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]
13. Bittl J. Advances in coronary angioplasty. N Eng J Med 1996;335:1290-1302.[Free Full Text]
14. Bypass Angioplasty Revascularization Investigation (BARI) investigators. Comparison of coronary bypass surgery with angioplasty in patients with multivessel disease. N Engl J Med 1996;335:217-225.[Abstract/Free Full Text]
15. Versaci F., Gaspardone A., Tomai F., Crea F., Chiariello L., Gioffre P. A comparison of coronary-artery stenting with angioplasty for isolated stenosis of the proximal left anterior descending coronary artery. N Engl J Med 1997;336:817-822.[Abstract/Free Full Text]
16. Serruys P., de Jaegere P., Kiemeneij F., et al. A comparison of balloon expandable stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489-495.[Abstract/Free Full Text]
17. EPIC Investigators. Use of monoclonal antibody directed directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994;330:956-961.[Abstract/Free Full Text]
18. Serruys P., Emanuelsson H., van der Giesen W., et al. Heparin-coated Palmaz-Schatz stents in human coronary arteries. Early outcome of the Benestent-II pilot study. Circulation 1996;93:412-422.[Abstract/Free Full Text]

Related Article

Piet Boonstra
Ann. Thorac. Surg. 1999 68: 911-912. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

				J. G. Byrne, M. Leacche, D. E. Vaughan, and D. X. Zhao Hybrid Cardiovascular Procedures J. Am. Coll. Cardiol. Intv., October 1, 2008; 1(5): 459 - 468. [Abstract] [Full Text] [PDF]

				T. A. Vassiliades Jr, J. S. Douglas, D. C. Morris, P. C. Block, Z. Ghazzal, S. T. Rab, and C. U. Cates Integrated coronary revascularization with drug-eluting stents: Immediate and seven-month outcome J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 956 - 962. [Abstract] [Full Text] [PDF]

				G. Davidavicius, F. Van Praet, S. Mansour, F. Casselman, J. Bartunek, I. Degrieck, F. Wellens, R. De Geest, H. Vanermen, W. Wijns, et al. Hybrid Revascularization Strategy: A Pilot Study on the Association of Robotically Enhanced Minimally Invasive Direct Coronary Artery Bypass Surgery and Fractional Flow Reserve-Guided Percutaneous Coronary Intervention Circulation, August 30, 2005; 112(9_suppl): I-317 - I-322. [Abstract] [Full Text] [PDF]

				G. J Murphy, R. Ascione, and G. D Angelini Coronary artery bypass grafting on the beating heart: surgical revascularization for the next decade? Eur. Heart J., December 1, 2004; 25(23): 2077 - 2085. [Abstract] [Full Text] [PDF]

				G. J. Murphy, A. J. Bryan, and G. D. Angelini Hybrid Coronary Revascularization in the Era of Drug-Eluting Stents Ann. Thorac. Surg., November 1, 2004; 78(5): 1861 - 1867. [Abstract] [Full Text] [PDF]

				S. K. Singh, S. K. Mishra, D. Kumar, R. D. Yadave, and S. K. Sinha Multivessel Total Arterial Revascularization via Left Thoracotomy Asian Cardiovasc Thorac Ann, March 1, 2004; 12(1): 30 - 32. [Abstract] [Full Text] [PDF]

				V. J. Amodeo, H. W. Donias, G. D'Ancona, E. L. Hoover, and H. L. Karamanoukian The Hybrid Approach to Coronary Artery Revascularization: Minimally Invasive Direct Coronary Artery Bypass with Percutaneous Coronary Intervention Angiology, November 1, 2002; 53(6): 665 - 669. [Abstract] [PDF]

				K. D. Stahl, W.D. Boyd, T. A. Vassiliades, and H. L. Karamanoukian Hybrid robotic coronary artery surgery and angioplasty in multivessel coronaryartery disease Ann. Thorac. Surg., October 1, 2002; 74(4): S1358 - 1362. [Abstract] [Full Text] [PDF]

				M. Cisowski, W. Morawski, J. Drzewiecki, W. Kruczak, K. Toczek, J. Bis, and A. Bochenek Integrated minimally invasive direct coronary artery bypass grafting and angioplasty for coronary artery revascularization Eur. J. Cardiothorac. Surg., August 1, 2002; 22(2): 261 - 265. [Abstract] [Full Text] [PDF]

				T. Isomura, H. Suma, T. Horii, T. Sato, T. Kobashi, and H. Kanemitsu Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure Ann. Thorac. Surg., December 1, 2000; 70(6): 2017 - 2022. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Antonio M. Calafiore Gianni D. Angelini Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lloyd, C. T. Articles by Angelini, G. D. Search for Related Content PubMed PubMed Citation Articles by Lloyd, C. T. Articles by Angelini, G. D. Related Collections Related Article