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Ann Thorac Surg 2003;76:635-637
© 2003 The Society of Thoracic Surgeons

How to do it

Off-pump long onlay bypass grafting using left internal mammary artery for diffusely diseased coronary artery

Shuichiro Takanashi, MDa*, Toshihiro Fukui, MDa, Yasuyuki Hosoda, MDa, Yoshihiro Shimizu, MDb

a Department of Cardiovascular Surgery Shin-Tokyo Hospital, Chiba, Japan
b Department of Cardiovascular Surgery Osaka City General Hospital, Osaka, Japan

Accepted for publication December 6, 2002.

* Address reprint requests to Dr Takanashi, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba 271-0077, Japan
e-mail: takanashi-s{at}gem.hi-ho.ne.jp


   Abstract
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 Abstract
Introduction
 Technique
 Results
 Comment
 References
 
Surgical treatment of a diffusely diseased coronary artery has been considered a relative contraindication for off-pump coronary artery bypass grafting. To our knowledge, long onlay-patch grafting with off-pump coronary artery bypass grafting has not been described. Two sets of Octopus 3 tissue stabilizers were placed longitudinally along the target coronary artery. This allowed us to perform surgical angioplasty and bypass grafting without cardiopulmonary bypass support (double Octopus technique). We report our early experience with off-pump long onlay bypass grafting in patients with a diffusely diseased coronary artery using double Octopus tissue stabilizers.Diffusely diseased coronary artery; off-pump coronary artery bypass grafting; coronary artery reconstruction; coronary artery bypass grafting; onlay patch anastomosis


   Introduction
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 Abstract
 Introduction
Technique
 Results
 Comment
 References
 
To avoid the adverse effects of cardiopulmonary bypass (CPB), off-pump coronary artery bypass grafting has gained increased popularity in recent years. The Octopus tissue stabilizer (Medtronic, Inc, Minneapolis, MN.) has been available for such procedures and its safety and efficacy have been well described in the literature [1]. Multivessel off-pump revascularization has been performed with acceptable results. One of the relative contraindications for off-pump surgical procedures is diffuse atherosclerosis requiring endarterectomy, angioplasty, or both because of the difficulty of holding the operative field steady along the long length of the coronary artery with a stabilizer.

In our institution, the off-pump surgical option has been used for patients requiring surgical angioplasty with the new operative technique. Here we report our early experience with off-pump long onlay bypass grafting using the left internal mammary artery (LIMA) and the double Octopus technique in patients with diffuse disease of the left anterior descending coronary artery (LAD).


   Technique
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 Technique
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A median sternotomy is performed, and the LIMA is harvested in fully skeletonized fashion using an ultrasonic scalpel. Diluted milrinone lactate is injected into the harvested graft to reverse vasospasm. The pericardium is opened, and deep pericardial traction sutures are placed when the anastomoses are carried out on the posterior wall of the heart. For clear visualization of the LAD, gauze pads are placed behind the heart. Atheromatous plaques on the artery are observed carefully through the adventitia or palpated by a surgeon’s finger, and the length of the arteriotomy is planned.

The first Octopus tissue stabilizer is placed distal to the targeted section of the coronary artery and the second, on the proximal part of the artery (Fig 1). Thus, the whole length of the coronary lesion is immobilized, and a steady operative field for the anastomosis of the diffusely diseased coronary artery is provided by the two sets of stabilizers. A silicone elastomer snare suture is placed proximally and tightened to achieve hemostasis in the operative field, and a carbon dioxide blower facilitates the anastomosis by providing a blood-free field.



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  		Fig 1. (A) Two Octopus tissue stabilizers are applied to the proximal and distal portions of the arteriotomy. (B) A long anastomosis is accomplished.

 
A longitudinal arteriotomy of 4 to 6 cm is made on the target coronary artery. The most proximal major stenotic lesion is left alone to avoid competitive flow. Distally the arteriotomy is extended to nondiseased intima. A longitudinal incision is also made in the LIMA so that the length of the distal orifice of the LIMA matches the length of the arteriotomy on the LAD. The anastomosis is carried out in an onlay fashion using a running suture of 8-0 polypropylene. The sutures are placed so as to exclude the atheromatous plaques from the lumen of the coronary artery (coronary artery reconstruction using LIMA). All coronary branches, such as the septal and diagonal branches, are preserved.

The antithrombotic protocol consists of low-dose ticlopidine hydrochloride and aspirin for 3 months and then aspirin alone.


   Results
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From April 2001 to July 2002, we performed 13 long onlay-patch angioplasties on the LAD using the LIMA. The mean age of the patients was 59.1 years, and 69.2% were male. The mean anastomosis time was 33 minutes (range, 19 to 57 minutes). The mean length of the onlay anastomosis was 4.9 cm (range, 4 to 6 cm). Hemodynamics during the procedure were stable in all patients. No perioperative myocardial infarction was observed.

All patients underwent postoperative angiographic study within 10 days, and all grafts and LADs were patent (Fig 2). All patients continue to be free from recurrent angina during follow-up (range, 1 month to 15 months).



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  		Fig 2. (A) Preoperative angiogram demonstrates a diffusely diseased left anterior descending coronary artery (LAD). (B) Postoperative angiogram showing a long onlay-patch graft of the left internal mammary artery on the LAD.

 

   Comment
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To date, the treatment of diffuse coronary artery atherosclerotic disease has been endarterectomy and onlay patch grafting under CPB [2, 3]. Barra and colleagues [4] reported coronary artery reconstruction, by long onlay bypass grafting using arterial conduit for diffuse and extensive coronary artery atherosclerotic lesions. The patency rate of the IMA grafts after plaque exclusion and surgical angioplasty using the IMA was 95% at 2 years. However, they performed the operation with CPB.

Diffusely diseased coronary arteries that require a long anastomosis have been considered unsuitable for off-pump coronary artery bypass grafting [5]. We have been able to safely perform long onlay graftings without CPB using the double Octopus technique. This technique provides a wider, well-immobilized operative field. A proximal snare suture and a carbon dioxide blower are effective in maintaining a relatively bloodless field. It is a difficult technique, and probably a large expansion of off-pump coronary artery bypass grafting surgery is necessary. We presume that the myocardium can stand a rather long period of ischemia because the existent collateral circulation usually is well developed in patients with a severely diffusely diseased artery. If a long period of ischemia causes deleterious hemodynamic effects, conversion to CPB should be considered without hesitation.

The problems in terms of endarterectomy are intimal hyperplasia and plaque emboli. Because our plaque exclusion technique with the IMA, which is known to be more resistant to intimal hyperplasia than the saphenous vein, does not require plaque immobilization from the vessel wall, it should be free from the risk of distal emboli.

We have demonstrated in 13 patients the possibility of performing coronary artery reconstruction without the use of CPB. Patients who have a severe diffuse coronary lesion and are a high risk for CPB will benefit from this technique.


   References
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 Abstract
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 Technique
 Results
 Comment
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  1. Scott N.A., Knight J.L., Bidstrup B.P., Wolfenden H., Linacre R.N., Maddern G.J. Systematic review of beating heart surgery with Octopus Tissue Stabilizer. Eur J Cardio-thorac Surg 2002;21:804-817.[Abstract/Free Full Text]
  2. Shapira O.M., Akopian G., Hussain A., et al. Improved clinical outcomes in patients undergoing coronary artery bypass grafting with coronary endarterectomy. Ann Thorac Surg 1999;68:2273-2278.[Abstract/Free Full Text]
  3. Sankar N.M., Satyaprasad V., Rajan S., Bashi V.V., Cherian K.M. Extensive endarterectomy, onlay patch, and internal mammary bypass of the left anterior descending coronary artery. J Card Surg 1996;11:56-60.[Medline]
  4. Barra J.-A., Bezon E., Mondine P., Resk A., Gilard M., Boshat J. Coronary artery reconstruction for extensive coronary disease: 108 patients and two-year follow-up. Ann Thorac Surg 2000;70:1541-1545.[Abstract/Free Full Text]
  5. Jansen E.W., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]



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