Ann Thorac Surg 1999;68:1540-1541
© 1999 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, The Christ Hospital, and Division of Cardiac Surgery, The Jewish Hospital, Cincinnati, Ohio, USA
Address reprint requests to Dr Wolf, Department of Minimally Invasive Cardiac Surgery and Robotics, The Ohio State University Medical Center, Doan Hall 8 N, 410 West 10th Ave, Columbus, OH 43210;
Presented at Evolving Techniques and Technologies in Minimally Invasive Cardiac Surgery, San Antonio, TX, Jan 2223, 1999.
Background. It has been stated that thoracoscopic internal thoracic artery (ITA) mobilization is not recommended in the redo minimally invasive direct coronary artery bypass (MIDCAB) situation, presumably because adhesions from the previous coronary artery bypass grafting operation may preclude a thoracoscopic approach. However, there are advantages to thoracoscopic ITA mobilization in MIDCAB that could also be realized in the redo situation.
Methods. In 200 MIDCAB procedures over the last 3 and a half years, 11 patients, ages 4983 (mean 69), were identified as having undergone an attempted ITA mobilization in a redo situation.
Results. Thoracoscopic ITA mobilization was successful in 9 out of 11 patients (81%). One patient had complete pleural symphysis precluding this approach, and 1 patient had poor mammary flow after harvest and this conduit was not used. Both failures were in female octogenarians.
Conclusions. To realize the advantages of a thoracoscopic ITA mobilization MIDCAB, both right and left thoracoscopic ITA mobilization can safely be performed in the redo situation. Thoracic adhesions precluding a thoracoscopic approach were encountered in only 1 of 11 redo coronary artery bypass grafting patients.
Redo coronary artery bypass grafting (CABG) is associated with significant morbidity, including the risk of atheroemboli from manipulation of degenerated grafts. In targeted redo CABG operations, the minimally invasive direct coronary artery bypass (MIDCAB) technique avoids manipulation of old grafts as well as of the ascending aorta. There has been some reluctance to attempt thoracoscopic mammary artery mobilization for MIDCAB in redo CABG operations, presumably because adhesions from the previous CABG may preclude a thoracoscopic approach.
Material and methods
The records of 200 patients undergoing a minimally invasive CABG operation over the last 3 and a half years were reviewed. In 11 patients, 7 men and 4 women, ages 4983 (mean age 69 years) a redo MIDCAB with left or right internal thoracic artery mobilization was attempted thoracoscopically. Of the 11 patients, 9 had one sternotomy for CABG and 2 patients had two.
The left or right internal thoracic artery (ITA) is visualized thoracoscopically with a 10-mm, 30-degree thoracoscope with 68 mm Hg insufflation (Fig 1). Two stab wounds are used in the third and seventh intercostal spaces for introduction of a Harmonic scalpel (Ethicon EndoSurgery, Cincinnati, OH) and an endoscopic Kitner (Ethicon EndoSurgery, Cincinnati, OH). The Harmonic scalpel is used to mobilize the ITA from the first to fifth ribs and coagulate all branches.
Pleural adhesions prevented a thoracoscopic approach in only 1 patient. In another patient, an 82-year-old woman undergoing her second redo CABG, the ITA was mobilized thoracoscopically. However, there was poor flow through the conduit when opened distally, and the conduit was not utilized. In the remaining 9 patients, seven left and two right ITAs were successfully mobilized thoracoscopically. In these 9 patients, seven left anterior descending and two old right vein grafts were the targets. All nine operations were successful as judged by intraoperative or postoperative arteriogram and/or intraoperative transonic ultrasound (Fig 2). There were no postoperative elevations of creatine phosphokinase. In the patient with a complete left pleural symphysis, an "H" graft was constructed between the intact left ITA and the left anterior descending artery (LAD). In the 1 patient in whom the left ITA was damaged during harvest, a pedicled gastroepiploic was successfully placed to bypass the LAD. One patient expired within 30 days of ischemic bowel secondary to mesenteric artery occlusion. The thoracoscopic ITA harvest was successful in nine out of eleven attempts (81%) in redo CABG situations. Of the 9 successful thoracoscopic ITA mobilizations in redo patients, 8 remain alive and angina-free from 630 months postoperatively (mean 18 months).
Redo CABG is associated with significant morbidity, including the risk of atheroemboli from manipulation of degenerated saphenous grafts. In targeted redo CABG operations, the MIDCAB technique can avoid manipulation of old grafts as well as of the ascending aorta. In MIDCAB procedures, we routinely mobilize the ITA utilizing a completely thoracoscopic approach. Totally thoracoscopic ITA mobilization technique has been previously reported . The advantages of a completely thoracoscopic mammary harvest include: (1) minimal chest wall trauma; (2) mobilization to and above the first rib for a longer mammary conduit which can lie comfortably on the mediastinum; and (3) the anterolateral thoacotomy incision can be made directly over the proposed anastomotic site, minimizing the mobilization of the heart in the adherent pericardium. With care, adhesions between lung and mediastinum can be safely divided. This was possible in all but 1 patient. It is recommended that all redo patients in whom an ITA mobilization is planned undergo a preoperative ITA angiogram study to assess ITA patency as well as course. The exact course of the ITA, be it straight or tortuous, is useful information to the surgeon during mobilization.
In redo CABG patients undergoing ITA mobilization, thoracoscopic mobilization is possible and safe. A less invasive procedure can be accomplished with thoracoscopic ITA mobilization, because the thoracotomy incision would be performed directly over the proposed anastomotic site, decreasing manipulation of the pericardium and possibly old degenerated saphenous grafts. Also, the anterior surface of the heart is not manipulated during thoracoscopic ITA mobilization.
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