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): Kaan Kirali Tuncer Koçak Füsun Güzelmeriç Deniz Göksedef Nihan Kayalar Cevat Yakut Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kirali, K. Articles by Yakut, C. Search for Related Content PubMed PubMed Citation Articles by Kirali, K. Articles by Yakut, C. Related Collections Coronary disease

Ann Thorac Surg 2004;78:1598-1602
© 2004 The Society of Thoracic Surgeons

---

Original article: cardiovascular

Off-Pump Awake Coronary Revascularization Using Bilateral Internal Thoracic Arteries

^a Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Istanbul, Turkey
^b Department of Cardiovascular Anesthesia, Kouyolu Heart and Research Hospital, Istanbul, Turkey

Accepted for publication May 17, 2004.

^* Address reprint requests to Dr Kirali, Department of Thoracic and Cardiovascular Surgery, Kouyolu Heart and Research Hospital, 81020 Kadköy, Istanbul, Turkey
imkkirali{at}yahoo.com

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: A new technique has been developed that permits complete arterial revascularization of the lateral and/or inferior wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, without cardiopulmonary bypass and mechanical ventilation, creates the least invasive revascularization method for the lateral and/or posterior wall of the heart yet described.

METHODS: In 7 patients double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started one hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique by standard median sternotomy. Circumflex, or the right coronary artery, were anastomosed with bilateral internal thoracic arteries using a heart positioner. Six patients received double bypass grafting and one patient received triple bypass grafts (bilateral internal thoracic arteries and one radial artery).

RESULTS: All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in three patients, but it was repaired in two. Only one patient completed the procedure with unilateral pneumothorax. There were no hemodynamic and pulmonary problems during lateral or posterior wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses.

CONCLUSIONS: Complete arterial revascularization by median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach gives a chance for awake revascularization of the right and/or circumflex coronary artery.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Whereas the main progress in cardiac surgery is avoidance of cardiopulmonary bypass in the 20th century, the new millennium allows us to avoid general anesthesia and mechanical ventilation during cardiac operations. A new strategy to reduce the invasiveness of cardiac surgery has recently been described [1]. This new strategy prevents the side effects of cardiopulmonary bypass and mechanical ventilation and general anesthesia. On the other hand, usage of arterial grafts for coronary artery bypass grafting is the most important point to get significantly better long-term result [2].

We believe that using in situ arterial graft is the best strategy. A simple new surgical procedure for the harvesting and use of bilateral internal thoracic arteries (ITA) is described here for complete arterial revascularization in conscious patients. There are some reports about coronary bypass surgery in awake patients [3–7], but we have found no report in the literature about using bilateral ITAs in conscious patients. Preferring an isolated semiskeletonization technique for harvesting ITAs allows a maximum length of bilateral ITAs and avoids pleural opening during harvesting, since incision of the pericardium at the left or right upper edge without pleural opening protects these in situ arterial grafts from tension after circumflex or right coronary artery anastomosis.

	Material and Methods

Top Abstract Introduction Material and Methods Results Comment References

 
Between October 2003 and March 2004, 7 conscious patients were operated on by the first author for complete coronary revascularization with only arterial grafts, using high thoracic epidural anesthesia at Kouyolu Heart and Research Hospital, Istanbul, Turkey. This study was approved by the Institutional Review Board of the hospital, and written informed consent was obtained from all participants. Patients were fully informed about the pros and cons of the surgical approach (including that this technique is new and long-term results are not yet available) and a written informed consent was obtained. Patient selection criteria included the absence of recent antithrombotic (< 1 week) or fibrinolytic therapy (< 2 days), presence of significant (> 70%) stenosis, good-caliber target vessels (> 1 mm), the presence of two inflow grafts (bilateral ITAs), and patient cooperation. Any potential comorbidity (diabetes mellitus, chronic obstructive pulmonary disease, chronic renal failure) did not affect patient selection. All ß-blockers were stopped 2 days before operation.

This technique was used in seven male patients with a mean age of 53.6 ± 9.8 years (range, 40 to 69 years). The patients' weights were between 70 and 78 kg (74 ± 4 kg), and body surface area was between 1.75 m² and 1.9 m² (1.83 ± 0.05 m²). Four patients had a previous myocardial infarction, but only one patient had left ventricular dysfunction (ejection fraction 40%). The other six patients had normal left ventricular function (ejection fraction > 50%). One patient had left main coronary disease. No patient had any peripheral vascular or carotid disease. Two patients had diabetes mellitus; one patient had chronic renal failure. Only one patient had chronic obstructive pulmonary disease. The mean forced vital capacity was 3.68 ± 0.51 L (range, 2.84 to 4.2 L), and the mean predicted percentage was 93.01% ± 14.43% (range, 69.9% to 115%). The mean ratio between the forced expiratory volume in 1 second and forced vital capacity was 83.64% ± 5.23% (range, 74.6% to 89.7%).

Epidural Anesthesia
High thoracic epidural anesthesia was used for these operations. No muscle-paralyzing agent or general anesthetic agent was used. The objective of this approach is to achieve somatosensory and motor block at the T1 to T8 level and motor block of the intercostal muscles while preserving diaphragmatic respiration. One hour before the operation, the patient is premedicated with 0.07 mg/kg midazolam and is placed in a sitting position; then a 16-gauge flexible-tip catheter (Perifix Soft 505, B Braun, Melsungen, Germany) is inserted through a Tuohy needle at the T1 to T2 interspace, employing the median approach and the loss-of-resistance technique. The catheter is directed cephalad and advanced 3 to 4 cm in the epidural space. An epidural anesthesia solution, consisting of bupivacaine hydrochloride, lidocaine, fentanyl, and sodium bicarbonate, is used for continuous epidural anesthesia. Sensory block level is maintained at the C6 to T8 level. The block level is tested after epidural administration of a test dose of 5 mL lidocaine (2%) as a bolus. Fifteen minutes later, the level of the block is tested by assessing both temperature and pin prick discrimination. Loss of temperature discrimination is deemed necessary to continue the operation with epidural anesthesia. Motor block of the intercostal muscles is assessed visually by monitoring the loss of intercostal movement. At least 60 minutes elapses between epidural catheter insertion and heparinization. In all operations 5,000 IU of heparin is used for anticoagulation, which is not reversed with protamine at the termination of the operation.

The patients are draped in a manner that would give free and unrestricted access for the anesthesiologist to manipulate the head and neck of the patient, in case an urgent tracheal intubation should be necessary. Monitoring of the patients includes only continuous electrocardiogram (lead DII), direct arterial pressure, central venous pressure, and pulse oxymetry.

The operating room is kept warm and only warm intravenous fluids are used. Throughout the operation, patients spontaneously breathe oxygen (4 L/min) through a face mask. We usually do not use any medication for sedation, but if the patient is excited we give a small dose of propofol (0.5 mg/kg). Local anesthetic ointments are used before placement of epidural and invasive catheters. If the patient has pain in the upper or lower wound, a small dose of local anesthesia (lidocaine) can be used, especially during sternotomy.

Surgical Technique
After standard median sternotomy, the left ITA is harvested first. A retractor is used to elevate the left or right sternal half. The loose areolar tissue and pleural reflection immediately posterior to the sternum are dissected away and pushed down using a low cautery setting. We never peel off this tissue from the chest wall with a sterile gauze, because this maneuver can cause a wide pleural opening. After palpation of the left ITA, an initial small incision ( 1 cm) of the endothoracic fascia is performed by electrocautery along the medial side of the accompanying internal thoracic vein at the fourth rib (Fig 1). Then the endothoracic fascia is taken down and incised by scissors proximally and distally at the full length of the ITA. The lateral incision is never necessary. The edge of the endothoracic fascia is then grasped with a forceps and the ITA is harvested using the tip of the cold cautery as a dissector. Major branches are ligated with double hemostatic clips and divided by scissors, and the small branches are divided by electrocautery. Both internal thoracic veins are left intact at the chest wall. Then the ITA pedicle with surrounding thin tissue is easily mobilized from the endothoracic fascia (Fig 2). Terminal division usually occurs at the sixth intercostal space, before lateral musculophrenic and superior epigastric branches, to preserve this distal bifurcation for avoidance of excessive sternal devascularization. The first branch must be divided to get more mobility. The ITA is left intact and wrapped in a papaverine-soaked sponge.

View larger version (29K): [in this window] [in a new window]   Fig 1. A small incision is made at the medial side of the internal thoracic artery. (LIMA = left internal mammary artery.)

View larger version (34K): [in this window] [in a new window]   Fig 2. The side branches are ligated with double hemostatic clips and divided by scissors. The internal thoracic artery pedicle with surrounding thin tissue is easily mobilized from the endothoracic fascia.

View larger version (38K): [in this window] [in a new window]   Fig 3. Right internal thoracic artery (ITA) to the left anterior descending artery and the left ITA to circumflex anastomosis.

If the right ITA is used for the right coronary system, the pericardium is incised 10 mm right of the aorta and the incision is carefully lengthened 4 to 5 cm down parallel to the right phrenic nerve and vena cava superior. This maneuver allows the right ITA to lie intrapericardially as it courses to the right coronary artery branches. Because the right ITA now lies medial and posterior to the lung, ventilation does not produce any distortion or stretching of the right ITA. The left ITA can be used very simply to revascularize the LAD without the incision of the left pericardium.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
There was no perioperative myocardial infarction or mortality. No patient was converted to cardiopulmonary bypass and global cardioplegic arrest. All patients completed the procedure awake. We did not observe any Horner syndrome. Only three patients required an additional dosage of local anesthesia, and we injected lidocaine into the jugulum in one patient and into the lower wound (round the xiphoid) in two patients.

Mean operative duration was 197.5 ± 28.2 minutes (range, 165 to 235 minutes). The intraoperative heart rate (mean, 68 ± 7 beats/min; range, 57 to 78) was adequate to perform distal anastomoses, and the mean intraoperative arterial pressure was 129 ± 9 mm Hg (range, 111 to 137 mm Hg). Mean stay in the intensive care unit was 18.8 ± 2.2 hours (range, 16 to 21 hours), and mean discharge from the hospital was 5.7 ± 1.9 days (range, 3 to 7 days). Mean chest tube drainage was 512.5 ± 160.1 mL (range, 400 to 750 mL), but no patient received any blood products.

All anastomoses were performed using a mechanical stabilizer and starfish positioner. Six patients received double bypass grafting (3 right ITA to LAD and left ITA to circumflex system; 2 left ITA to LAD and right ITA to right coronary artery or posterior descending artery), and 1 patient received triple bypass grafting (right ITA to LAD, left ITA to circumflex, radial artery to right coronary posterior descending artery); the mean bypass number was 2.14 ± 0.4. There were no intraoperative electrocardiographic changes. The rhythm was sinus during the whole procedure in all patients. Lateral or inferior wall exposure was accomplished with acceptable hemodynamic performance. Two patients (28.5%) required unexpected coronary endarterectomy during circumflex anastomosis (1 cm open and 1 cm closed) and right coronary posterior descending artery anastomosis (1 cm open and 3 cm closed). The distal soft silicone elastomer tape was loosened to perform distal endarterectomy. Both arteries were grafted as long segments (1 cm) with ITA. We did not observe any myocardial ischemia and/or arrhythmia during endarterectomy. During the postoperative period we did not observe any myocardial ischemia on the electrocardiographs. There was no atrial fibrillation or ventricular arrhythmia during the operation and postoperative period.

During surgery, we provided patients with oxygen face masks, thus maintaining oxygen saturation levels consistently more than 95%, as measured by pulse oximetry. Mean intraoperative arterial carbon dioxide pressure (PaCO₂) was 53.8 ± 9.5 mm Hg, and mean intraoperative oxygen saturation (SO₂) was 98.4% ± 1.5%. The pleura were opened in three patients and were repaired in two of them. The pleural defect was as a small hole in both patients and was repaired primarily after catheter aspiration of the air in the pleural space was carried out. Only one patient (14.3%) had unilateral pneumothorax during this procedure, and the lung was allowed to collapse. But the patient did not have any respiratory distress during the procedure. The mean PaCO₂ level was 40 ± 6.5 mm Hg, and mean SO₂ level was 98% ± 1.8% in the intensive care unit. All patients were awake in the intensive care unit and none required intubation. No patient had any pulmonary complication (atelectasis, pneumothorax, infection) and none required pulmonary therapy.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
A new operative strategy must have some goals, but also some principles. This new operative strategy has the following advantages: using in situ arterial grafts (bilateral ITAs) for multivessel coronary revascularization in patients with lateral and/or posterior wall disease (stabilizer, starfish); reducing the possibility of wound complications (semiskeletonization of ITAs); avoidance of cardiopulmonary bypass (off-pump); avoidance of aortic manipulation; avoidance of possible complications caused by endotracheal intubation and mechanical ventilation and general anesthesia (conscious bypass procedure); none, or a short period stay in the intensive care unit (very early mobilization); short hospital stay (very early discharge); and lower cost. On the other hand, the main advantages of the high thoracic epidural anesthesia on the cardiac hemodynamics (bradycardia, absence of arrhythmias during manipulation of the heart, no perioperative and postoperative atrial arrhythmias, coronary vasodilatation, and ITA dilatation) provide excellent technical conditions for beating-heart surgery and excellent graft flow [3, 4].

The main goal during coronary revascularization is to secure a nontraumatized artery with maximum length and diameter, and adequate flow. The skeletonization techniques of ITAs improve the length and allow more distal and sequential grafting [8–10]. Avoidance of the wide dissection of the sternum may reduce wound complications due to the preservation of limited collateral blood supply to the sternum. To leave the bifurcation of lateral musculophrenic and superior epigastric branches intact prevents excessive sternal devascularization. Semiskeletonization prevents a pleural opening in the spontaneously breathing patient, and a limited dissection also allows a limited postoperative bleeding. If it is necessary, the pericardium can be incised lateral of the pulmonary artery to prevent the ITA from pleural tension [11]. Because the ITAs are free of surrounding veins, fascia, and lymphatic tissue, the left ITA can be anastomosed to the circumflex branches or the right ITA to the distal right coronary artery branches. The last 2 to 3 cm part of the ITA has surrounding tissues, which make it easy to handle the artery during anastomosis.

Unilateral, widely opened pleura are not necessarily a reason for a conversion to general anesthesia, but bilateral opened pleura cannot be tolerated by a conscious patient. The left ITA is usually harvested first. If the left pleura are opened wide during sternotomy or harvesting of the left ITA, or primary repair of a small hole is unsuccessful, the decision must be made to convert to general anesthesia before the harvesting of the right ITA because of the possibility of opening the right pleura. The second alternative is to use the left radial artery for the other anastomosis without converting to general anesthesia. The second point for avoidance of pneumothorax is not to use deep pericardial traction sutures, which can cause an unexpected small hole on the pleura.

Avoidance of general anesthesia and positive pressure ventilation for complete arterial revascularization of the lateral or inferior wall coronary artery extends the spectrum of less invasive operative procedures. Significant complications after coronary bypass surgery are often associated with preexisting pulmonary disease or reduced general health status. This often requires prolonged postoperative ventilatory support and a prolonged intensive care unit stay. Avoidance of mechanical ventilation, cardiopulmonary bypass, and general anesthesia are the main advantages of awake coronary bypass surgery with increased risks [3, 4]. Patients with multivessel disease can benefit from this new operative strategy. In this series, we did not observe any pulmonary complication, such as atelectasis or pulmonary infection, after surgery. This strategy will have better outcome in patients with severe pulmonary disease like bullous lungs and chronic obstructive pulmonary disease, by avoiding mechanical complications (barotrauma, decreasing of mucociliary activity) of mechanical ventilation, which can be caused by hyperinflation, overpressure, and positive end expiratory pressure. The potential risks of endotracheal intubation (trauma to teeth or vocal cords, periintubational hypoxia) are also avoided.

Some authors performing awake coronary bypass surgery do not use the intensive care unit and they discharge their patients directly to wards [1, 6]. We also perform single vessel coronary revascularization in awake patients. Our preferred approach for single vessel is reverse J sternotomy [12]. With this minimally invasive strategy we have begun bypassing the intensive care unit and discharged our patients from the hospital on the second postoperative day. Because we are at the beginning of this new technique (using bilateral ITAs), we did not wish to bypass the intensive care unit. For this reason, our patients stayed in the intensive care unit between 16 and 21 hours. In this present series, the last patient was discharged from the hospital on the third postoperative day. We hope that we will bypass the intensive care unit and discharge patients earlier after we finish our learning curve. This end point means no intensive care unit, very short hospital stay (< 2 days), and a significant decrease of hospital costs.

There are some limitations for this strategy. The patient must be cooperative for this procedure. Any pathology on the spinal cord is the main contraindication. Preoperative bleeding tendencies are the other major contraindication because of the risk of epidural bleeding. Bilateral pneumothorax may inhibit the operative strategy, but a small hole on the pleura or unilateral pneumothorax can be tolerated. Obesity can be a problem because of the need for a high dose of epidural anesthesia, which can cause intraoperative severe bradicardia, or intraoperative or postoperative apnea.

The pioneers of awake coronary bypass surgery have emphasized that further studies are required to define the possible extent and limitations of this strategy [3, 4]. We have shown that there is no limitation for using bilateral ITAs and revascularizing lateral circumflex branches or the right coronary posterior descending artery using off-pump devices, without any hemodynamic deterioration. This approach allows ideal access to all regions of the heart and facilitates multivessel arterial revascularization.

In conclusion, bilateral ITAs can be used safely and successfully for complete arterial revascularization in conscious patients. Awake coronary bypass surgery techniques might have better early and late results because of the proven long-term patency of ITAs (versus new stent models), no intensive care unit stay, short hospital stay (< 3 days), lower cost, and early return into normal life. We also believe that this new operative strategy with new minimally invasive modifications (like T sternotomy) might, in the future, be a serious alternative against interventional cardiologic methods (stent applications) in patients with multivessel disease.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Karagöz H, Sönmez B, Bakkaloglu B, et al. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg. 2000;70:91–96[Abstract/Free Full Text]
2. Nishida H, Tomizawa Y, Endo M, Koyanagi H, Kasanuki H. Coronary artery bypass with only in situ bilateral internal thoracic arteries and right gastroepiploic artery. Circulation. 2001;104(suppl 1):I-76–80
3. Karagöz HY, Kurtolu M, Bakkalolu B, Sönmez B, Çetint T, Bayazit K. Coronary artery bypass grafting in the awake patient: three years' experience in 137 patients. J Thorac Cardiovasc Surg. 2003;125:1401–1404[Abstract/Free Full Text]
4. Aybek T, Kessler P, Khan MF, et al. Operative techniques in awake coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125:1394–1400[Abstract/Free Full Text]
5. Zenati MA, Paiste J, Williams JP, Strindberg G, Dumouchel JP, Griffith BP. Minimally invasive coronary bypass without general endotracheal anesthesia. Ann Thorac Surg. 2001;72:1380–1382[Abstract/Free Full Text]
6. Paiste J, Bjerke RJ, Williams JP, Zenati MA, Nagy GE. Minimally invasive direct coronary artery bypass surgery under high thoracic epidural. Anesth Analg. 2001;93:1486–1488[Abstract/Free Full Text]
7. Vanek T, Straka Z, Brucek P, Widimsky P. Thoracic epidural anesthesia for off-pump coronary artery bypass without intubation. Eur J Cardiothorac Surg. 2001;20:858–860[Abstract/Free Full Text]
8. Cartier R, Leacche M, Couture P. Changing pattern in beating heart operations: use of skeletonized internal thoracic artery. Ann Thorac Surg. 2002;74:1548–1552[Abstract/Free Full Text]
9. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg. 1992;54:947–951[Abstract]
10. Horii T, Suma H. Semiskeletonization of internal thoracic artery: alternative harvest technique. Ann Thorac Surg. 1997;63:867–868[Abstract/Free Full Text]
11. Mansurolu D, imanolu M, Ömerolu SN, Kirali K, Ipek G, Yakut C. A simple method to prevent internal thoracic artery tension: single pericardiothoracic suture technique. J Card Surg 2004;19:264–6
12. Krali K, Kayalar N, Özen Y, et al. Reversed-J inferior sternotomy for coronary artery bypass surgery under high thoracic epidural anesthesia. 53rd International Congress of the European Society for Cardiovascular Surgery, 2–5 June 2004, Ljubljana, Slovenia

This article has been cited by other articles:

				Y. Kato, I. Matsumoto, S. Tomita, and G. Watanabe A novel technique to prevent intra-operative pneumothorax in awake coronary artery bypass grafting: biomaterial neo-pleura Eur. J. Cardiothorac. Surg., January 1, 2009; 35(1): 37 - 41. [Abstract] [Full Text] [PDF]

				N. Noiseux, I. Prieto, D. Bracco, F. Basile, and T. Hemmerling Coronary artery bypass grafting in the awake patient combining high thoracic epidural and femoral nerve block: first series of 15 patients Br. J. Anaesth., February 1, 2008; 100(2): 184 - 189. [Abstract] [Full Text] [PDF]

				K. Kirali, N. Kayalar, T. Kocak, and C. Yakut Reversed-J inferior sternotomy for awake coronary bypass Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 923 - 924. [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): Kaan Kirali Tuncer Koçak Füsun Güzelmeriç Deniz Göksedef Nihan Kayalar Cevat Yakut Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kirali, K. Articles by Yakut, C. Search for Related Content PubMed PubMed Citation Articles by Kirali, K. Articles by Yakut, C. Related Collections Coronary disease