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Ann Thorac Surg 2003;76:919-921
© 2003 The Society of Thoracic Surgeons

Case report

Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure

Michal Semrad, MD, PhDa*, Martin Stritesky, MD, PhDa, Vladimir Vondracek, MD, PhDa, Jaroslav Lindner, MD, PhDa, Ivan Vanek, MD, PhDa, Jan Kristof, MDa, Michael Aschermann, MD, PhDb

a Department of Cardiovascular Surgery, Charles University Teaching Hospital, 1st Medical Faculty, Prague, Czech Republic,
b II Internal Department, Charles University Teaching Hospital, 1st Medical Faculty, Prague, Czech Republic

Accepted for publication October 27, 2002.

* Address reprint requests to Dr Semrad, Department of Cardiovascular Surgery, Charles University Teaching Hospital, 1st Medical Faculty, U nemocnice 2, 12800, Prague 2, Czech Republic.
e-mail: semrad{at}post.cz


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Minimally invasive direct coronary artery bypass grafting (MIDCABG) is a well-known technique for coronary artery bypass grafting performed under direct vision without sternotomy, aortic manipulation, or cardiopulmonary bypass. The left internal mammary artery (LIMA) may be taken down either under direct vision or thoracoscopy. In a small group of patients who are candidates for MIDCABG [1], the left subclavian artery is stenosed or occluded or the LIMA is damaged during harvesting, precluding the use of this graft. Additionally there is an increasing number of patients requiring reoperation in whom the LIMA has already been used. In those cases a pedicled right gastroepiploic artery graft could be used. When alternative conduits are needed a proximal aortic anastomosis needs to be performed [2]. It is not easy to reach the ascending aorta and place a side-biting clamp from a small left anterior thoracotomy approach and there are alternatives to overcome this problem [3]. We propose an easier method to create, in such instances, a video-assisted port access proximal anastomosis in the ascending aorta with an automated mechanical anastomosis device (Symmetry Aortic Connector System, St.Jude Medical ATG, St. Paul, MN).

A 79-year-old man was transferred from a district cardiology department with unstable angina not responsive to maximal medical therapy. Coronary artery angiography revealed a proximal left anterior descending artery (LAD) occlusion (Fig 1, A) and immediate catheter-based therapy was unsuccessful. Transthoracic echocardiography (ECHO) showed an anterolateral wall motion abnormality and 45% global ejection fraction of the left ventricle. Several preoperative risk factors were identified. In addition to advanced age and urgency of operation the patient had a history of diabetes, hypertension, and peripheral and cerebrovascular artery disease. The decision to perform an urgent MIDCABG procedure was made and written consent, including the possibility of performing a port access vein graft automated proximal anastomosis, was obtained.



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  		Fig 1. (A) Preoperative angiogram showing proximal left anterior descending artery occlusion. (B) Postoperative angiogram showing a saphenous vein graft to left anterior descending artery with widely patent anastomoses.

 
The patient was prepared as for routine conventional cardiac surgery. A transesophageal echocardiography (TEE) probe and Swan-Ganz pulmonary artery catheter were inserted. Combined thoracic epidural anesthesia was induced with a single lumen endotracheal tube, which was advanced by endoscopy to the right main stem bronchus before LIMA dissection. In this way we achieved unilateral lung ventilation in all MIDCABG cases. A weak left radial artery pulse and a difference in arterial blood pressure between upper extremities were found in the operating room; TEE detected a 90% stenosis at the origin of the left subclavian artery. There was no ascending aortic atheroma.

An 8-cm left anterior thoracotomy was performed in the fifth intercostal space without rib excision and a 15-cm segment of saphenous vein was harvested from the right leg. A pediatric rib retractor was positioned and the pericardium opened longitudinally from midportion to ascending aorta with bipolar scissors. The ascending aorta was visualized using pericardial traction stitches and a rigid 30-degree endoscope (Olympus A 5195A/OTV-S6; Olympus Optical, Tokyo, Japan). An appropriate site for the proximal vein graft anastomosis was selected. As it is necessary to insert an aortic connector at a 90-degree angle, a suitable region on the left lateral chest wall was located. This could only be performed accurately with video assistance. Once an appropriate area was found a small skin incision was made and a 12-mm metal Olympus port was passed through the intercostal space into the pleural cavity.

Passing any straight and narrow instrument through the port towards the ascending aorta permitted us to confirm the correct 90-degree angle positioning. The 5.25-mm outer diameter vein graft was loaded onto the Symmetry Aortic Connector and heparin, 1.5 mg/kg, was administered. The camera was positioned and the aortic cutter was passed through the port to the target area. This was followed by passage of the loaded delivery device (Fig 2). For a brief period from the time the aortic cutter was removed until the moment the delivery system was positioned bleeding was controlled using a small tampon on the tip of a hemostat. The graft was deployed, properly measured and shortened, to reach the distal anastomosis without kinking.



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  		Fig 2. The Symmetry Aortic Connector reaching the ascending aorta from a port through the second intercostal space.

 
Since 2000 we have used the Octopus II (Medtronic, Minneapolis, MN) vacuum stabilizer in all MIDCABGs because our experience shows that it may offer better exposure of the frequently displaced LAD. In our procedure we do not use any loops or stay sutures around the coronary arteries and we do use intraluminal shunts routinely. Finally, the trocar incision was used for chest tube placement and the left anterior thoracotomy was closed. The time to construct the proximal anastomosis was 2 minutes, the skin-to-skin operative time was 72 minutes, and length of stay in the intensive care unit was 8 hours.

Postoperative pain control was achieved with epidural analgesia; low molecular weight heparin was given for 5 days and aspirin was continued indefinitely. The entire postoperative course was uneventful and the patient was discharged 6 days after surgery with normal anterior wall motion and global ejection fraction of 58% as determined by echocardiography. An angiographic evaluation of graft patency was performed before discharge (Fig 1, B). Eight months after operation the patient was leading an active life with no angina.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
The broadest definition of minimally invasive bypass surgery is reduction of trauma related to incision, cardiopulmonary bypass, and aortic manipulation [4]. MIDCABG fulfils this definition in all aspects. In this report we wanted to demonstrate the applicability and potential advantages of the sutureless aortic connector system to port access proximal anastomosis construction. This device provides a means for avoiding aortic manipulation but it is not appropriate for radial arteries. Three potential problems a surgeon might encounter when using the Symmetry Bypass System are (1) extensive atheromatous plaques in the ascending aorta, (2), leakage from the automated anastomosis, and (3) excessive graft length with possible kinking and stenosis. Preoperative assessment of the aorta wall together with proper graft deployment precluded any anastomotic leak. A sharp angulation immediately distal to the proximal anastomosis should be avoided in left-sided grafts by placing them toward the left lateral aspect of the aorta wall. There was no body habitus or skin-to-aorta distance limitation for port access vein graft deployment.

We have observed three advantages in the port access approach when compared with its only alternative, the subclavian/axillary artery to coronary artery bypass (SAXCAB): operative time is shorter; the resultant aesthetic benefit of a submammary incision and a small port incision is considerable; and the automated anastomosis is round-shaped and better looking at control angiography compared with a hand-sewn one, although the long-term patency of automated anastomoses is not yet proven.

We have found only one major contraindication to this procedure: a calcified ascending aorta, which precludes safe graft deployment. In such cases we recommend performing a SAXCAB.

The Symmetry Aortic Connector System can be used with minimal access. The advantages outlined in this report and cost effectiveness need to be evaluated in comparison with standard methodologies. Nevertheless port access using mechanical anastomotic devices represents a form of less invasive coronary surgery. In cases where a LIMA cannot be harvested or is damaged in a MIDCABG procedure video-assisted port access proximal anastomosis with the Symmetry aortic connector may be an alternative to the SAXCAB procedure. This may reduce the time needed for a lateral MIDCABG to the circumflex system [5]. A modification of the on-pump Dresden procedure [6], video-assisted multivessel revascularization using a left anterior small thoracotomy approach with an automated mechanical anastomosis device, may be particularly useful for patients undergoing coronary artery bypass reoperation or for patients at risk of poor sternum healing or infection. Investigation of these areas remains ongoing in our group.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Subramanian V.A., Patel N.U. Current status of MIDCAB procedure. Curr Opin Cardiol 2001;16:268-270.[Medline]
  2. Kawata T., Kameda Y., Taniguchi S. Modification of repeat coronary bypass grafting for the left anterior descending artery with a minimally invasive direct coronary artery bypass technique. J Card Surg 1999;14:366-369.[Medline]
  3. Coulson AS, Glasgow EF, Bonatti J. Minimally invasive subclavian/axillary artery to coronary artery bypass (SAXCAB): review and classification. Heart Surg Forum 2001;13–25
  4. Mack MJ. Era of ‘minimization’: defining and reducing surgical trauma for cardiac patients. Faculty abstract in: Neurologic injury during cardiac surgery II: a call to arms. Available at: http://www.embolx.com/neuroinjury/pages/sym2/sym2.html
  5. Stamou S.C., Bafi A.S., Boyce S.W., et al. Coronary revascularization of the circumflex system: different approaches and long term outcome. Ann Thorac Surg 2000;70:1371-1378.[Abstract/Free Full Text]
  6. Gulielmos V., Brandt M., Knaut M., et al. The Dresden approach for complete multivessel revascularization. Ann Thorac Surg 1999;68:1502-1505.[Abstract/Free Full Text]



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