Ann Thorac Surg 2001;71:384-385
© 2001 The Society of Thoracic Surgeons
How to do it
Redo left anterior descending artery grafting via left anterior small thoracotomy: an alternative approach
Paul C. Kerr, DO, FACSa,
Marco Ricci, MD, PhDa,
Reginald Abraham, MDa,
Giuseppe D’Ancona, MDa,
Tomas A. Salerno, MDb
a Division of Cardiothoracic Surgery, Buffalo General Hospital and SUNY at Buffalo, Buffalo, New York, USA
b Division of Cardiothoracic Surgery, University of Miami/Jackson Memorial Hospital, Miami, Florida, USA
Accepted for publication June 4, 2000.
Address reprint requests to Dr Kerr, Division of Cardiothoracic Surgery, Buffalo General Hospital, 100 High St, Buffalo, NY 14203
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Abstract
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Reoperative left anterior descending artery (LAD) revascularization can be performed through a left anterior small thoracotomy (LAST approach) in patients requiring isolated LAD revascularization. If the left internal mammary artery has been previously used, however, the operation is generally performed either through a median sternotomy or through a full posterolateral thoracotomy for the necessity of connecting the vein graft to the ascending aorta or to the descending thoracic aorta, thus losing the advantages of a minimally invasive approach. In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the left internal mammary artery as the inflow site of a saphenous vein coronary graft to the LAD.
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Introduction
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Isolated revascularization of the left anterior descending coronary artery (LAD) through a left anterior small thoracotomy (LAST procedure) without using cardiopulmonary bypass (CPB) has been recently popularized by Calafiore and associates [1] in an attempt to avoid both median sternotomy and extracorporeal circulation. Although the validity of this strategy of revascularization has been convincingly substantiated by several reports [2, 3], this technique can be employed only in a small subset of patients presenting with critical coronary artery disease limited to the LAD territory. However, as the indications for the LAST operation have expanded, this procedure has been recently proposed as an alternative to conventional reoperative coronary artery bypass grafting (CABG) in patients requiring reoperative LAD revascularization, thus avoiding the hazards of sternal reentry [4]. In such patients, as in those undergoing primary LAST operation, the left internal mammary artery (LIMA) can be mobilized and used for LAD grafting, with minimal dissection of the heart from previous adhesions. In patients in whom the LIMA has been previously used, however, the LAST operation is frequently precluded, as a segment of saphenous vein needs to be used to revascularize the LAD. As a result, a more invasive approach is commonly required to connect the vein graft to the ascending aorta (median sternotomy), or to the descending thoracic aorta (standard posterolateral thoracotomy), thereby losing the advantages of a minimally invasive strategy of revascularization (LAST operation).
In the case reported herein, we describe a technique in which reoperative revascularization of the LAD is accomplished through the LAST approach, using the stump of the LIMA as the inflow site of a saphenous vein coronary graft to the LAD.
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Technique
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The operation is initiated by placing the patient on the operating table in a supine position. The left chest is entered through a left anterior small thoracotomy of approximately 6 to 7 cm in length performed on the fifth intercostal space (Fig 1). As the pericardium is opened, the LAD is identified, dissecting a limited area of antero-lateral wall of the heart from adhesions related to the previous CABG. Of note, one of the advantages of this approach in the setting of coronary reoperations is that it minimizes the dissection required to expose the LAD, as compared with conventional redo CABG. In patients in whom the previous revascularization had encompassed a LIMA-to-LAD graft that subsequently occluded, redo LAD revascularization is accomplished by using a segment of reversed saphenous vein as a conduit. The distal anastomosis to the LAD is performed on the beating heart by using a pressure-type mechanical stabilizer that is connected to one of the blades of the chest retractor (CTS, Cupertino, CA) (Fig 1). A second skin incision is made just below the left clavicle (Fig 1), in a manner similar to that used to approach the axillary artery. After dividing the pectoralis major muscle, the subclavian artery and the left internal mammary artery at its origin are identified beneath the subclavian vein (Fig 1). The saphenous vein graft is then brought up into the subclavicular area through the left pleural cavity. Partial resection of the second rib considerably facilitates exposure and minimizes the risk of graft kinking. The proximal anastomosis of the saphenous vein graft is constructed end-to-end to the proximal stump of LIMA using 7-0 Prolene in a running fashion, 1 to 2 cm distal to the origin of this vessel from the left subclavian artery.
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Fig 1. Redo LAST operation (bottom) combined with a left subclavicular incision to isolate the origin of the LIMA (top). A saphenous vein graft is interposed between the origin of the LIMA and the LAD (right).
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Comment
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The use of both subclavian and axillary arteries as inflow sites of coronary grafts has been previously advocated mostly in the management of patients with severe atherosclerosis of the ascending aorta, to prevent embolization and stroke during construction of proximal anastomoses [5]. In contrast, in the case reported herein, we have used the stump of the LIMA as the source of a coronary graft that was connected to the LAD using a left anterior small thoracotomy. Our patient previously underwent CABG in which the LIMA was used. As the proximal LAD and the LIMA had occluded, this conduit could not be used to revascularize the LAD during the reoperation. Its proximal portion, however, was found to be patent as a result of collaterals arising from the first segment of the LIMA.
The advantages of this technique are that a minimally invasive approach (LAST approach) can still be adopted even in patients in whom the LIMA cannot be used for grafting. These patients would be otherwise treated by converting the anterior small thoracotomy to a full posterolateral thoracotomy, losing the benefits of a less invasive approach, or would be treated by redo revascularization via median sternotomy with all the risks related to sternal reentry and extensive dissection of the heart from adhesions. In addition, connecting the vein graft to the stump of LIMA minimizes the dissection of the subclavian artery, and renders the proximal anastomosis technically easier as compared with directly using the subclavian artery as an inflow source. The subclavian artery, however, may be used advantageously in patients undergoing redo LAD or circumflex revascularization, in whom a functioning LIMA-to-LAD graft is already present.
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References
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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]
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Calafiore A.M., Di Giammarco G., Teodori G., et al. Midterm results after minimally invasive coronary surgery (LAST operation). J Thorac Cardiovasc Surg 1998;115:763-771.[Abstract/Free Full Text]
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Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1997;64:1648-1653.[Abstract/Free Full Text]
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Boonstra P.W., Grandjean J.G., Mariani M.A. Reoperative coronary artery bypass grafting without cardiopulmonary bypass through a small thoracotomy. Ann Thorac Surg 1997;63:405-407.[Abstract/Free Full Text]
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Suma H. Coronary artery bypass grafting in patients with calcified ascending aorta: aortic no-touch technique. Ann Thorac Surg 1989;48:728-730.[Abstract/Free Full Text]
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Abstract
Introduction
