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Ann Thorac Surg 2006;81:800-806
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Use of Bilateral Internal Thoracic Arteries in CABG Through Lateral Thoracotomy With Robotic Assistance in 150 Patients

Sudhir Srivastava, MD d , * , Suresh Gadasalli, MD b , Madhava Agusala, MD b , Ram Kolluru, MD b , Jayaram Naidu, MD b , Manish Shroff, MD c , Reyna Barrera, PAC d , Shaune Quismundo, RN d , Vishwa Srivastava, BA a , d

a Department of Cardiovascular Surgery, Odessa, Texas
b Department of Cardiology, Odessa, Texas
c Alliance Hospital, Odessa, Texas
d Cardiac Surgical Associates, Odessa, Texas

Accepted for publication August 22, 2005.

* Address correspondence to Dr Sudhir Srivastava, 710 East 6th St, Odessa, TX 79761 (Email: sudhirpsrivastava{at}mac.com).

Presented at the Forty-first Annual Meeting of The Society of Thoracic Surgeons, Tampa, FL, Jan 24–26, 2005.


Dr S. Srivastava discloses a financial relationship with Intuitive Surgical Inc and Medtronic Inc.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system.

METHODS: Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management.

RESULTS: Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 ± 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 ± 2.9 days.

CONCLUSIONS: The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.

Myocardial revascularization with aortocoronary bypass graft surgery (CABG) has been performed in the United States for more than 40 years now, first introduced using the saphenous vein and within a year, using the internal thoracic artery (ITA) [1]. The ITA bypass has been shown to yield superior clinical results in studies ranging up to 20 years [1, 2] and has now become the standard of care based on reports of superior graft patency, reduced major adverse cardiac events, and enhanced survival when compared with patients receiving only venous conduits [3, 4]. The use of ITA has several advantages including a low incidence of atherosclerosis [1], functional arterial endothelium, ideal coronary-to-conduit size match, and capacity for flow regulation in response to varying myocardial demand [5].

Observational studies comparing single and double ITA grafts have demonstrated a benefit in terms of both survival and freedom from major adverse cardiac events. Clinical and angiographic outcomes of bilateral internal thoracic artery (BITA) has shown to be superior to single ITA grafting with supplemental vein grafts, when pedicled, sequential, or free aortocoronary internal mammary artery was used [4–7]. Bilateral ITA grafting has also been identified as an independent predictor of lower rates of angina recurrence, late myocardial infarction, and the composite endpoint of any cardiac event [3, 6].

In recent years, the use of skeletonized ITA grafts has received attention as a means of enhancing the versatility of this conduit. The dissected artery is longer, allowing the use of both ITAs as grafts potentially to all target coronary vessels [8].

The use of robotically enhanced manipulation provided by the da Vinci Robotic System (Intuitive Surgical, Sunnyvale, California), with the three-dimensional view and wristed instruments, has made the harvesting of BITA through port incisions and CABG through thoracotomy possible, thereby decreasing surgical trauma [9]. The author has previously described complete coronary revascularization through a left anterolateral thoracotomy (ThoraCAB) [10]. The present report deals with the use of BITA through a thoracotomy approach.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
From July 2002 through July 2004, after signing informed surgical consent, 150 patients underwent harvesting of BITAs with the da Vinci Robotic System and subsequent thoracotomy (ThoraCAB) for coronary revascularization. Institutional Review Board submission was not required as the da Vinci robotic system had been approved for ITA harvesting.

Patient Selection
The study included patients diagnosed with coronary artery disease requiring CABG, reoperations with stenosed grafts or new disease, and staged hybrid revascularization with percutaneous intervention and excluded patients with history of left lung surgery, empyema, unstable hemodynamics, acute cerebrovascular accident, severe chronic obstructive pulmonary disease with inability to tolerate one-lung anesthesia, and extremely dilated heart.

Anesthesia for the Endoscopic Procedure
All patients have a radial arterial catheter and Swan-Ganz catheter placed for hemodynamic monitoring. After induction of anesthesia, a double-lumen endotracheal tube is inserted for single-lung ventilation. All patients have a transesophageal echocardiographic probe inserted to assess the cardiac function, before the start of the procedure. Intravenous nitroglycerin drip is continued throughout the procedure.

Patient Position
The patient is placed in supine position with an inflatable pressure bag under the left scapula to facilitate opening of the intercostal spaces as well as down displacement of the left shoulder to accommodate the right instrument arm movements. The left arm is allowed to hang on the side supported by a sponge and sheets. Skin preparation from the chin to the toes of both lower extremities is done using antiseptic solutions.

Operative Technique
Three 1- to 2-cm incisions are made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line (Fig 1). In patients with shorter chests, the incisions are made in the second, fourth, and sixth intercostal space. After deflating the left lung, a camera port is inserted through the middle incision and carbon dioxide insufflation is initiated and maintained at an average of 10 mm Hg. In patients with fatty mediastinum, the carbon dioxide insufflation pressure may be increased to 12 to 15 mm Hg as long as patients are able to maintain satisfactory hemodynamic status. A 30-degree angle-up camera is inserted, and the thoracic cavity is examined as well as the location and course of the left internal thoracic artery (LITA). The left and the right instrument ports are inserted under direct vision of the camera. The surgical cart with the three mechanical arms is brought in and attached to the camera and the instrument arm ports.


Figure 1
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  		Fig 1. Skin markings showing port positioning for the camera arm in the fifth intercostal space (5th ICS), left instrument arm in the seventh intercostal space (7th ICS), and right instrument arm in the third intercostal space (3rd ICS).

 
At this stage, the surgeon sits on the surgeon's console, and while looking through the three-dimensional viewer, initiates the telemanipulation of the camera and the instrument arms. The mediastinal pleura is dissected off the chest wall, and the right pleural cavity is entered. The right internal thoracic artery (RITA) is harvested completely in a totally skeletonized fashion using a 0-degree camera in the majority of the cases. Hemoclips are used for larger branches, while the cautery is used to cauterize and transect the smaller branches. Occasionally, the internal thoracic artery is harvested with the accompanying veins after incising the fascia in case of close proximity of arteries and veins. After this, the LITA is harvested in the similar fashion using a 30-degree angle-up camera.

The LITA is left attached to the chest wall with the connecting areolar tissue to prevent it from hanging over the pericardium (Fig 2). Pericardiotomy is done anteriorly extending to the distal part of the ascending aorta. Care is taken to leave 2 inches of pericardium covering the apex of the left ventricle. Systemic heparin, 2 mg/kg, is administered, and hemostat clips are applied at the distal end of the RITA and LITA. Activated clotting time is monitored every 30 minutes, and additional heparin doses are given to maintain activated clotting time over 300 seconds. The transected arteries between the clips are secured to the pericardial fat using hemostat clips to prevent migration or distortion. The left anterior descending artery (LAD) is inspected for suitability of grafting RITA to LAD. In the event RITA will not reach LAD, and still having the endoscopic view, it will be transected for later use as a free graft.


Figure 2
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  		Fig 2. Completed dissection of right internal thoracic artery (RITA) and left internal thoracic artery (LITA) and pericardiotomy showing left anterior descending artery (LAD) through left thoracotomy.

 
Before making a thoracotomy, 0.5% marcaine is injected along the line of the camera port incision. This incision is then extended between 6 and 10 cm depending on the number of distal anastomoses, the location of the target arteries, and the need for proximal anastomosis on the ascending aorta. After placement of the Medtronic retractor (Medtronic, Minneapolis, MN), pericardial sutures are placed to bring the ascending aorta in view for proximal anastomoses when needed. Proximal anastomoses are done first when indicated, followed by distal anastomoses using Octopus 4, Octopus NS, or Octopus TE (Medtronic). A T, Y, or end-to-end anastomosis is constructed between RITA and LITA using U-Clips (Medtronic) when RITA is used as a free graft. All anastomoses were handsewn using the U-Clip Anastomotic Device (Medtronic) for all distal anastomoses (Figs 3, 4, and 5). Go Go


Figure 3
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  		Fig 3. Exposure and completed anastomosis of left internal thoracic artery (LITA) to left anterior descending artery (LAD).

 

Figure 4
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  		Fig 4. Exposure and completed anastomosis of saphenous vein graft (SVG) to right coronary artery (RCA) through left thoracotomy.

 

Figure 5
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  		Fig 5. Exposure and completed anastomoses of obtuse marginal branch one (OM1) and obtuse marginal branch two (OM2) with left internal thoracic artery (LITA) through left thoracotomy.

 
Flow measurements are done on most grafts using Medi-Stim (Medtronic). Heparin is reversed with protamine. The pericardium is loosely closed over the heart to prevent herniation. Cryoanalgesia is produced using a cryoprobe (Frigitronic, Shelton, CT) in three to four intercostal spaces posteriorly. A 19F Blake drain is placed in the right pleural cavity and brought out through the left instrument arm port incision. A 24F Blake drain is placed in the left pleural cavity through the right instrument port incision. The left lung is reinflated, and the ribs are approximated using 2-Ethicon nonabsorable suture in a figure-of-eight fashion (Ethicon Inc, San Angelo, TX). Two On-Q Pump (I-Flow, Lake Forest, CA) catheters are placed through the skin into the spaces between the muscle layer and the ribs and the muscle layer and the subcutaneous tissue. The skin is closed in a subcuticular manner using 4-0 Monocryl suture (Ethicon Inc). Dermabond topical skin adhesive (Ethicon, Raleigh, NC) is applied over the incision.

Postoperative Management
Intravenous nitroglycerin is continued in the intensive care unit for as long as 24 hours. Ketoralac, 30 mg, is given intravenously every 6 hours for 48 hours to patients without evidence renal insufficiency. In patients aged more than 70 years, ketoralac, 15 mg, is given every 6 hours for 48 hours. Precedex is titrated as a continuous drip in doses of 0.2 to 0.7 ug.kg an hour for pain control. Aspirin, 81 mg, and clopidogrel, 75 mg, are given either orally or through the nasogastric tube once the patient arrives in the intensive care unit. Clopidogrel, 75 mg per day, is continued for 3 months and aspirin, 81 mg per day, indefinitely.

Follow-Up for Pain Score
All patients completed a numeric pain scale survey from 0 to 10, with 0 meaning no pain and 10 meaning extreme pain. Reports of the pain score were obtained for the first postoperative day, 1 week, 1 month, and 3 months after the procedure (Fig 6).


Figure 6
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  		Fig 6. Comparison of pain score showing variable levels of pain at intervals of postoperative day 1 (dark blue bars), day 7 (orange bars), day 30 (yellow bars), and day 90 (green bars). Significant reduction of pain was noted after postoperative day 7.

 
Patient Demographics
There were 99 male and 51 female patients. The age range was 39 to 89 years with a mean of 67.2 ± 9.6 years. The ejection fraction ranged from 25% to 70% with a mean of 50.7% ± 9.0%. Preoperative risk factors are listed in Table 1. Patients who had prior thoracic surgery, severe chronic obstructive pulmonary disease, body mass index greater than 35 kg/m2, and known history of empyema were excluded from this group.


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  		Table 1. Preoperative Risk Factors
 

   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
Successful BITA harvesting was done on all patients. There were no injuries to BITA during harvesting. In 2 patients, BITA could not be used because of inadequate flow in 1 and spontaneous dissection in the other. Total grafts per patient ranged from 2 to 5 with a mean of 2.6 ± 0.8. The graft distribution is listed in Table 2. In 56 patients, in situ LITA was anastomosed to LAD and in situ RITA to RCA in 11 patients. In 40 patients, in situ RITA was anastomosed to LAD. A RITA to LITA T graft was done in 63 patients. In 25 patients, LITA to RITA composite grafting was done to anastomose RITA to posterior descending artery (PDA). Four patients received radial arterial grafts. There were 64 saphenous vein grafts. Total operative time was 311.6 ± 11.54 minutes with a median of 293 minutes. The BITA harvesting time ranged from 49 to 120 minutes with a mean of 74.3 ± 22.7 and median of 67 minutes. Postoperative hospital length of stay ranged from 1 to 17 days with a mean of 3.6 ± 2.9 and median of 3 days. Sixty-six percent of the patients were discharged in 4 days or less.


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  		Table 2. Graft Distribution
 
There was no operative death, myocardial infarction, cerebrovascular accident, renal failure, or wound infections. No patient required conversion to cardiopulmonary bypass. Five patients (3.3%) required reexploration for control of postoperative hemorrhage. In 3 patients, the site for bleeding was from the chest wall. The fourth patient had bleeding from a side branch of ITA, and in the fifth patient, the bleeding site was at the distal anastomosis. The control of hemorrhage was done through the original thoracotomy incision in 4 patients, and 1 patient required right minithoracotomy to control bleeding from the RITA harvest site. Seven patients (4.7%) developed new onset atrial fibrillation. Nineteen patients (13%) required transfusion of blood products (Table 3). Eight patients (5.3%) returned for thoracentesis because of pleural effusion. One patient required percutaneous intervention on the first postoperative day because of spasm of RITA to LAD graft. Two patients presented with chest pain after discharge. Occlusion of LITA to obtuse marginal branch graft in 1 patient and RITA to PDA graft in the other was noted on angiography. Both patients were successfully treated with percutaneous angioplasty. One patient with postoperative pleural effusion had lung herniation requiring reclosure of the thoracotomy. Fifty-five patients underwent computed tomography angiography with three-dimensional reconstruction at 3 months (Fig 7). There were 136 grafts performed in these 55 patients. All grafts were found to be patent. Pain score follow-up was done in all patients.


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  		Table 3. Postoperative Results
 

Figure 7
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  		Fig 7. Computed tomography angiogram at 3-month follow-up showing opacity beyond anastomoses, indicating graft patency.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
Three-dimensional visualization, magnification, and wristed instruments of the da Vinci Robotic System allows for precise harvesting of BITAs in a totally skeletonized fashion. There appears to be less trauma to the chest wall with this technique. It is important to keep the cautery to a low level to minimize thermal injury to the ITA. The skeletonized ITAs appear to be longer, allowing the potential use to all target coronary arteries [8]. Skeletonization of ITA in sternotomy cases as well reduces the risk of early sternal dehiscence and infection, particularly in elderly and diabetic patients [4]. That is mainly attributed to the partial preservation of collateral circulation to the sternum when the conduit is harvested in a skeletonized manner [11]. The internal mammary artery is nourished by the lumen, and because in the media, vasa vasorum is not present, the devascularization of the conduit does not have any adverse effect [12].

Proper port placement plays an important role in robotic ITA harvesting. It is important to telemanipulate the robotic arms and cover the areas of dissection to ensure a full range of accessibility by the instruments to the desired locations. Any adjustments in the position of the ports or the intercostal space through the ports are placed as well as the position of the robotic arms should be done before beginning the dissection. In female patients, the breast is positioned anteriorly and superiorly allowing for easier port placement and subsequent incision. Some additional features such as magnification, three-dimensional vision, a moving camera system, motion scaling, tremor elimination, and ergonomically aligned manipulators at the master console allow swift reduction of time for adaptation [7].

As in any new technology-based surgical innovation, there was a learning curve that was considered to be acceptable. The performance of this procedure may improve, especially with further technical development of the robotic system. With the inclusion of our previous report of ThoraCAB [10], subsequent nonrobotic and robotically harvested single ITA in ThoraCAB, and the present report, we have performed 800 complete coronary revascularizations through the ThoraCAB approach. The harvest of BITA was made possible only after the advent of robotic manipulation. Some advantages of minimal invasive techniques are obvious, such as reduction of wound infection, reduction of length of hospitalization, preservation of a stable thorax, earlier functional recovery, and excellent cosmetic results. There was a lower incidence for new onset atrial fibrillation in our series of patients. Multivariate analysis was not done to assess reasons for lower incidence of atrial fibrillation. For the purposes of this report, postoperative atrial fibrillation was defined as new onset atrial fibrillation requiring medications or electric cardioversion. The addition of cryoanalgesia and the I-flow On-Q Pump may reduce the incidence of the incisional chest pain. Although there is higher initial procedural cost for robotically enhanced surgery, the economic impact will require a thorough analysis of overall cost reduction secondary to early extubation, lower use of blood products, shorter length of stay, and earlier functional recovery.

Computed tomography angiography, although it has limitation of defining the quality of anastomoses, opacification of the conduit and the coronary artery beyond the anastomosis may show gross patency of the graft. Computed tomography angiography as compared with conventional coronary angiography appears to be more acceptable, particularly to the patients who are asymptomatic after the procedure. The introduction of 64-slice computed tomography scan may provide superior imaging results. In this study, the short-term graft patency appears satisfactory but additional follow-up is needed for long-term patency results.

There is a learning curve, and as experienced in other minimally invasive cardiac surgical procedures, the initial operative times are longer. Although in this group, no patient required conversion to cardiopulmonary bypass or sternotomy, patients can be placed on cardiopulmonary bypass by cannulating the aorta and right atrial appendage, or peripheral cannulation through the femoral artery and vein. Surgeons may choose a step-by-step approach to total revascularization through thoracotomy. One may start out with one or two anterior left-sided vessels and gradually incorporate other arteries as the exposure becomes easier. Surgeons who are currently using cardiopulmonary bypass may consider doing revascularization through thoracotomy on a beating heart with CPB.

In conclusion, robotic assistance has allowed the use of BITA through the ThoraCAB approach. The approach appears safe and feasible with low associated mortality and morbidity while providing earlier functional recovery. There may be reduction in pain with use of cryoanalgesia and the On-Q Pump. There appears to be a lower incidence of atrial fibrillation and use of blood products. The approach may be an evolutionary step to totally endoscopic coronary bypass surgery.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR BEN P. BIDSTRUP (Tugun, Queensland, Australia): I enjoyed your presentation. I think this paper and the earlier one on robotic surgery show how these innovative developments can be introduced into our practice. We are coming under increasing pressure, and hopefully we are going to put the cardiologists under increasing pressure because of the vast cost in most countries of drug-eluting stents. However, the robot isn't cheap. It has a huge capital outlay; in the United States, what is it, over 1 million dollars, and there are recurrent costs for the reusable robotic arms.

Can you give me some estimate whether the reduction in length of stay is likely to overtake the increased costs owing to the use of the robot, or to put it another way, have you amortized the increased cost of using the robot in these cases?

DR SRIVASTAVA: Thank you for the very good question, and I think it is a real practical concern in many hospitals. Yes, I think the initial capital outlay is a concern and probably turns some people away from buying a robot, but we have looked at the economics of all of this, and in fact one of these days we will share that data with you. What we have found is that apart from the initial purchase it can be amortized if one does three or four additional cases at least in the United States based on the reimbursement system.

Secondly, the average cost of the disposables is somewhere between $800 to $1,000. Many of these patients come out extubated in the operating room; they are not on many drugs; there is a very significant lower use of blood and blood products; and of course, the hospital length of stay, I think with more educational programs to our patients and the community, will all help achieve a reduction in the overall cost in this group of patients.

DR FRANK SELLKE (Boston, MA): Why do you think there is an advantage over a sternotomy with regard to pain control? Did you look at some of your OPCABG sternotomy patients and make a comparison between them and the current technique?

DR SRIVASTAVA: No, we did not, because we kind of stopped doing the sternotomies some years ago, and before that we really were not looking at that as a study. It is quite interesting that the surgeons somehow just have accepted the morbidity associated with a sternotomy as standard. So I am not so sure there are many studies out that truly have compared, and it probably would be a good idea to maybe have a matched patient base and look at it that way, maybe in a prospective way. We do not have it.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Cameron AA, Green GE, Brogno DA, Thornton J. Internal thoracic artery grafts20-year clinical follow-up. J Am Coll Cardiol 1995;25:188-192.[Abstract]
  2. Khot UN, Friedman DT, Pettersson G, Smedira NG, Li J, Ellis SG. Radial artery bypass grafts have an increased occurrence of angiographically severe stenosis and occlusion compared with left internal mammary arteries and saphenous vein grafts Circulation 2004;109:2086-2091.[Abstract/Free Full Text]
  3. Pick AW, Orszulak TA, Anderson BJ, Schaff HV. Single versus bilateral internal mammary artery grafts10-year outcome analysis. Ann Thorac Surg 1997;64:599-605.[Abstract/Free Full Text]
  4. Ascione R, Underwood MJ, Lloyd CT, Jeremy JY, Bryan AJ, Angelini GD. Clinical and angiographic outcome of different surgical strategies of bilateral internal mammary artery grafting Ann Thorac Surg 2001;72:959-965.[Abstract/Free Full Text]
  5. Flemma RJ, Singh HM, Tector AJ, et al. Comparative hemodynamic properties of veins and mammary artery in coronary bypass operations Ann Thorac Surg 1975;20:619-627.[Abstract]
  6. Rizzoli G, Schiavon L, Bellini P. Does the use of bilateral internal mammary artery (IMA) grafts provide incremental benefit relative to the use of a single IMA graft? A meta-analysis approach Eur J Cardiothorac Surg 2002;22:781-786.[Abstract/Free Full Text]
  7. Calafiore AM, Di Giammarco G, Teodori G, et al. Late results of first myocardial revascularization in multiple vessel diseasesingle versus bilateral internal mammary artery with or without saphenous vein grafts. Eur J Cardiothoracic Surg 2004;26:542-548.[Abstract/Free Full Text]
  8. Gurevitch J, Paz Y, Shapira I, et al. Routine use of bilateral skeletonized internal mammary arteries for myocardial revascularization Ann Thorac Surg 1999;68:406-411.[Abstract/Free Full Text]
  9. D'Attellis N, Loulmet D, Carpentier A, et al. Robotic-assisted cardiac surgeryanesthestic and postoperative considerations. J Cardiothorac Vasc Anesth 2002;16:397-400.[Medline]
  10. Srivastava SP, Patel KN, Skantharaja R, Barrera R, Nanayakkara D, Srivastava V. Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB)the first 200 cases. Ann Thorac Surg 2003;76:46-49.[Abstract/Free Full Text]
  11. de Jesus RA, Acland RD. Anatomic study of the collateral blood supply of the sternum Ann Thorac Surg 1995;59:163-168.[Abstract/Free Full Text]
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