Asian Cardiovasc Thorac Ann 1999;7:259-262
© 1999 Asia Publishing EXchange Pte Ltd
Videothoracoscopic Internal Mammary Artery Harvest for Coronary Bypass
Kaan Kirali, MD,
Mustafa Güler, MD,
Bahadir Da
lar, MD,
Gökhan Ipek, MD,
Mehmet Balkanay, MD,
Esat Akinci, MD,
Turan Berki, MD,
Ali Gürbüz, MD,
Ömer I
ik, MD,
Cevat Yakut, MD
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Department of Cardiovascular Surgery Kouyolu Heart and Research Hospital Istanbul, Turkey
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For reprint information contact: Kaan Kirali, MD Tel: 90 216 326 6969 Fax: 90 216 339 0441 email: kosuyolu{at}superonline.com Kouyolu Heart and Research Hospital, Kadiköy, Istanbul 81020, Turkey.
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Abstract
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Between March 1996 and September 1997, videothoracoscopy was performed in 50 of 140 patients who underwent minimally invasive coronary artery bypass grafting. Mean age was 45.3 ± 6.8 years. The left internal mammary artery was harvested by thoracoscopy alone in 21 patients and by both thoracoscopy and direct vision in 29. Coronary artery bypass was then performed through a left anterior minithoracotomy. In 48 patients, the internal mammary artery was grafted directly to the left anterior descending artery; a small saphenous vein graft was interposed in the other 2 patients. The diagonal branch was bypassed with saphenous vein in 2 patients, the first obtuse marginal in 1, the right posterior descending branch in 1, and the right ventricular branch of the right coronary artery in 1. Concomitant carotid endarterectomy was performed in 1 patient. There was no mortality. Two patients had perioperative myocardial infarction. It was concluded that videothoracoscopy can help to achieve complete mobilization of the left internal mammary artery for minimally invasive coronary artery bypass grafting. These techniques can be regarded as safe and effective, giving excellent results and a shortened hospital stay with the advantage of avoiding some morbidity due to costal cartilage resection.
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Introduction
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Since the introduction of thoracoscopy by Jacobeus1 in 1910, many exciting advances have been made in thoracic surgery. The availability of fiberoptic telescopes enabled excellent intrathoracic visual acuity as well as illuminated fields of view. Since 1990, video-assisted thoracoscopic surgery (VATS) has been used frequently in cardiac surgery.2–7 Benetti and Ballester8 first used VATS for left internal mammary artery (LIMA) harvesting in coronary bypass graft surgery.
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Patients and Methods
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Between March 1996 and September 1997, 50 patients underwent coronary bypass graft surgery using video-thoracoscopic LIMA harvesting in our institution. Thirty-eight (76%) were male and 12 (24%) were female. The patients' ages ranged between 33 and 69 years with a mean age of 45.3 ± 6.8 years. Preoperative risk factors and coexisting disorders are shown in Table 1
. Pre-operatively, it was established that the patient had never had pleuritis or any kind of surgical intervention on the side of the hemithorax where LIMA dissection was intended. Because of the single-lung ventilation during LIMA dissection, preoperative pulmonary function studies had to be normal.
The operation was carried out under general anesthesia with single-lung ventilation using a double-lumen endotracheal tube. The patient was positioned in the supine position with the left arm extended. A 5 to 7-cm left anterior thoracotomy was performed along the 4th intercostal space. The 4th rib cartilage was not excised. After evaluating the thoracic cavity for adhesions, trocars were introduced through 3 small thoracic incisions (< 1 cm) at the level of the 4th and 5th intercostal spaces along the medial and anterior axillary lines. The first step consisted of conducting a thorough exploration of the thoracic cavity and identifying and exposing the internal mammary artery. The LIMA was harvested with electrocautery from the level of the 6th or 7th rib to the subclavian artery. Perforated arterial branches were cauterized or clipped with a thoracoscopic stapler. The LIMA was harvested fully by videothoracoscopy in 21 patients; combined thoracoscopy and direct vision was employed in 29 patients. After dissection of the LIMA and placement of a rib spreader, a vertical incision was made on the pericardium along the trace of the left anterior descending artery (LAD). Traction sutures were placed on the edges of the opened pericardium and the heart was drawn anteriorly and medially until the LAD was centered in the wound. In some patients, a snare suture of elastic loop was placed proximal to the anastomosis site for control of coronary artery blood flow. No distal occlusions were carried out. The anastomosis was performed on a beating heart, without cardiopulmonary bypass, with 7/0 or 8/0 polypropylene suture and the aid of a gas jet to achieve a bloodless anastomotic area after a low dose of heparin (100 IU•kg–1). The heart rate was slowed with a beta-blocker (esmolol was infused in an initial dose of 500 µg•kg–1•min–1 for 2 minutes before coronary artery anastomosis, followed by a maintenance infusion of 200 µg•kg–1•min–1 until the end of the coronary artery anastomosis).
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Results
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The LIMA was grafted directly to the LAD in 48 patients. The middle section of the LIMA was damaged during harvesting in 1 patient and the length was insufficient in another, thus a short saphenous vein graft was interposed between the LIMA and LAD. Proximal anastomosis was made to the ascending aorta in these patients. In 1 patient who had satisfactory back flow from the proximal end of the inferior epigastric artery after transection of the LIMA, a saphenous vein graft was interposed between the proximal end of the inferior epigastric artery and a large right ventricular branch of the right coronary artery. The anastomoses are listed in Table 2. Preoperative and postoperative data are given in Table 3. There was no mortality. Two patients had perioperative myocardial infarction; both developed electrocardiographic changes in the 6th postoperative hour. Both patients were discharged from the hospital without any problems. Other morbidities are listed in Table 4.
At one year postoperatively, angiography was performed in 25 of the 50 patients, demonstrating a patent anastomosis in 24 of them. An occlusion of the distal segment of the LAD with retrograde perfusion was found in 1 patient. Eighteen of the other 25 patients had thallium perfusion scintigraphy at the end of the first postoperative year; all had normal myocardial perfusion except one patient who was known to have suffered a perioperative myocardial infarction. Treadmill tests were carried out in the other 7 patients, which were negative in all cases (Table 5).
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Discussion
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The anterior minithoracotomy associated with VATS has been used in clinical practice with some variations.9,10 The technique of LIMA harvesting by video assistance can be performed either thoracoscopically through 3 portholes in the left chest wall or by a combination of direct vision through a limited anterior thoracotomy incision and video assistance through a single port.5,11,12 In our study, after we had carried out a minithoracotomy, we evaluated the thoracic cavity for adhesions and then inserted trocars through the other 3 small incisions. This modification avoided lung injury which we regarded as a serious complication in our 2nd patient whose LIMA was harvested by this technique. The most important disadvantage of this technique is a longer harvesting time (> 45 minutes). Apart from possible technical pitfalls (pleural adhesions, bleeding, inadequate one-lung ventilation, cardiac enlargement), a longer harvesting time during the learning curve was the major disadvantage in the early phase of our experience. For this reason, we began to harvest the LIMA under direct vision and we observed that this technique needs a little more time than the VATS technique. Therefore, we think that with more experience, the bypass time and the length of the manipulation incision will be shortened.
The significant morbidity and invasiveness of conventional coronary artery bypass grafting arises primarily from 3 sources: cardiopulmonary bypass; the median sternotomy incision; and manipulation of the aorta.13–15 Patients operated via a small thoracotomy recover more quickly and are able to return to work in a much shorter time than those who have a conventional median sternotomy.13 The major advantages of this technique are avoidance of a sternotomy, minimized mediastinal trauma, and decreased chance of serious injury to the cardiac chambers or great vessels. Costal resection is never necessary with this technique and a small incision (5 to 7 cm) is sufficient to approach the LAD and carry out the anastomosis. Likewise, no retraction of the thoracotomy is necessary to expose the LIMA. Only anesthetic consideration might be a contraindication to the technique. It is essential that the patient should be able to tolerate single-lung ventila-tion that is contraindicated in severe pulmonary disease with insufficient reserve. For this reason, preoperative pulmonary function tests can help in patient selection. When the LIMA is harvested under direct vision, single-lung ventilation is not required because the pleura is not opened, thus pulmonary function is not compromised. Very high short-term (< 6 months) patency rates have been reported with these techniques.5,16,17 The patency rate at one year was high in this study, angiographically, 24 of 25 (96%) LIMA to LAD anastomoses were found to be patent.
This study demonstrated that a new and increasingly popular minimally invasive thoracic surgical technique was associated with a low and acceptable complication rate. This procedure is limited to single-vessel disease, usually of the LAD, although there is a small experience with bypass of the diagonal and intermediate branches of the left and right coronary arteries with right internal mammary artery and of the right posterior descending branch with right gastroepiploic artery.5,12,18
Presented at the Utrecht MICABG Workshop III, Utrecht, The Netherlands, September 26–27, 1997.
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References
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Abstract
Introduction
