HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article 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): Go Watanabe Takuro Misaki Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Watanabe, G. Articles by Ueyama, K. Search for Related Content PubMed PubMed Citation Articles by Watanabe, G. Articles by Ueyama, K.

J Thorac Cardiovasc Surg 1997;113:949-951
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

BILATERAL MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING WITH THE USE OF TWO ARTERIAL GRAFTS

Toyama, Japan

From the Department of Surgery (1), Toyama Medical and Pharmaceutical University, Toyama, Japan.

Received for publication Dec. 31, 1996 accepted for publication Jan. 8, 1997. Address for reprints: Go Watanabe, MD, Department of Surgery (1), Toyama Medical and Pharmaceutical University, Sugitani, Toyama 2630, 930-01, Japan.

Single-vessel coronary artery bypass grafting (CABG) of the left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) with minithoracotomy has been shown to produce excellent results with almost no mortality. ¹ However, this procedure is limited because only the LAD and diagonal branches are accessible through the left minithoracotomy. Furthermore, this procedure cannot be used in patients with double or triple vessel disease. We have developed a new technique that allows us to perform minimally invasive direct CABG in the setting of multivessel disease, using small bilateral anterior thoracotomies. Small left and right anterior thoracotomies and direct coronary artery revascularization with arterial grafts were performed in one patient. A new surgical approach to CABG for the LAD and right coronary artery (RCA), without the use of extracorporeal circulation, is described.

Case report.

A 47-year-old man had a history of increasing postinfarction angina and severe congestive heart failure. Cardiac catheterization revealed total occlusions of the proximal LAD, proximal RCA, and an obtuse marginal artery. Left ventriculography demonstrated diffuse hypokinesis and a left ventricular ejection fraction of 22%. Minimally invasive CABG with the LITA and the right gastroepiploic artery (RGEA) in situ was planned to revascularize the LAD and the RCA. The patient was intubated with a double-lumen endotracheal tube to permit selective ventilation. A limited anterior thoracotomy incision was performed in the third intercostal space, the cartilaginous portion of the third and fourth ribs was resected, and the pericardium was incised longitudinally (Fig. 1). A right lower parasternal incision was then made, extending from the sixth costal cartilage to 5 cm below the xiphoid process. The sixth and seventh costal cartilages were longitudinally incised. The pleura were incised lateral to the edge of the sternum and the right pleural cavity was entered. The pericardium was then incised, exposing the RCA and the right atrium. The LITA was harvested for a short length from the level of the second intercostal space to the level of the fifth intercostal space. The peritoneum was then opened in the midline, and the RGEA was harvested. After systemic heparinization (1 mg/kg), the LITA and RGEA were injected with 3 ml of a solution containing papaverine. The RGEA was then routed anterior to the pylorus and the left lobe of the liver and inserted into the pericardium through a hole in the diaphragm. The ends of the grafts were brought through the incision and prepared for grafting. Stay sutures were applied to the diaphragmatic pericardium and pulled upward, thus providing adequate exposure of the right atrioventricular sulcus. The anastomotic site of the LAD was dissected, and the LAD was then occluded proximally and distally with a 4-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) passed twice around the vessel. To avoid direct compression of the coronary artery, we passed the needle through a small piece of silicone tubing as described by Califiore and associates. ¹ Both 4-0 sutures were gently snared to ensure as bloodless an operative field as possible. The LITA-LAD anastomosis was completed without extracorporeal circulation with 8-0 propylene suture. The RCA (segment 3) was then surrounded with two 4-0 polypropylene looping sutures (Prolene), and the RGEA-RCA anastomosis was performed with a running 8-0 Prolene suture on the beating heart. Both pedicles were fixed next to the anastomosis sites. Heparin was reversed with protamine, bleeding was carefully controlled, and the thoracotomy was closed. Ventricular pacing wires and a single drainage tube were placed. The patient was extubated in the operating room. Neither blood nor inotropic drugs were required. Total operative time (initial incision to dressing) was 3 hours 30 minutes. The drainage tube was removed the day after the operation. An angiographic study, performed after the operation, showed patent LITA and RGEA grafts (Fig. 2). Discharge was 4 days after the operation. The patient was free of symptoms 4 months after the operation.

View larger version (50K): [in this window] [in a new window]   Fig. 1. A, The minithoracotomies consisted of a limited anterior thoracotomy incision in the third intercostal space and a right parasternal incision from the level of the sixth costal cartilage to the eighth costal cartilage and extending 5 cm below the xiphoid process. B, The right coronary artery was isolated between two slings with the previously dissected internal thoracic artery present in the operative field. ICS, Intercostal space; RA, right atrium; RV, right ventricle; RCA, right coronary artery; RGEA, right gastroepiploic artery.

View larger version (272K): [in this window] [in a new window]   Fig. 2. Top, Angiogram demonstrating the anastomosis between the LITA and the LAD. Bottom, The RGEA-RCA anastomosis is shown in left anterior oblique projection. Selective injection of the celiac trunk with visualization of the proximal portion of the pedicled RGEA.

The introduction of a minimally invasive cardiac procedure simplifies techniques for surgeons and improves postoperative results. ^1-3 CABG with the LITA used to bypass the LAD results in a 10-year patency rate of 85% to 90%. ⁴ In addition, the elective use of the RGEA as an in situ graft also has excellent patency rates. Recently, the use of a left minithoracotomy to perform the anastomosis between the LITA and the LAD has been advocated. The procedure can be performed on a beating heart with or without the aid of a thoracoscope ³ or with the support of extracorporeal circulation. ⁵ Minimally invasive CABG can be performed on the beating heart with surprisingly little hemodynamic disturbance, particularly when the native vessel is totally occluded. On the basis of this case report, we think that the minimally invasive CABG operation can be extended to patients with multivessel disease.

To retain the benefits of minimally invasive CABG and avoid the invasiveness of conventional CABG, we developed a new method of coronary revascularization in which we used bilateral minimally invasive CABG in a patient with multivessel disease. This method is suitable for treating patients with a proximally occluded or stenosed LAD or RCA. A right-sided minimally invasive CABG allows better exposure of the RCA and is recommended for those patients who require RGEA grafting. The procedure can be used with or without femorofemoral bypass. To the best of our knowledge, this is the first report of the use of bilateral minimally invasive CABG in a patient with multivessel disease. The utility of bilateral minimally invasive CABG with in situ arterial grafts has been demonstrated in the present study. The absence of a major thoracotomy may decrease patient discomfort, hospital stay, overall recovery time, and cost while providing the benefit of complete revascularization similar to that offered by standard open chest CABG. This technique is limited to revascularization of only the LAD and proximal RCA because of accessibility of the vessels. It should be emphasized that exposure of the posterior descending coronary artery for grafting is technically difficult with this approach. If the long-term results of LITA grafting to the LAD and RGEA grafting to the RCA can be accomplished with the use of this less invasive technique, a new surgical option for the management of multivessel coronary artery disease may be at hand.

References

1. Calafiore AM, Giammarco GD, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-65.[Abstract/Free Full Text]
   
2. Cosgrove DM, Sabik JF. Minimally invasive approach for aortic valve operations. Ann Thorac Surg 1996;62:596-7.[Abstract/Free Full Text]
   
3. Subramanian VA, Sani G, Benetti FJ, Calafiore AM. Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience. Circulation 1995;92(Suppl):1645.
   
4. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft of 10 year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
   
5. Westaby S, Benetti FJ. Less invasive coronary surgery: consensus from the Oxford meeting. Ann Thorac Surg 1996;62:924-31.[Free Full Text]
   

This article has been cited by other articles:

				S. Nishida, Y. Kikuchi, G. Watanabe, M. Takata, S. Ito, and K. Kawachi Endoscopic Radial Artery Harvesting: Patient Satisfaction and Complications Asian Cardiovasc Thorac Ann, February 1, 2008; 16(1): 43 - 46. [Abstract] [Full Text] [PDF]

				M. Takahashi, G. Watanabe, H. Furuta, T. Doi, N. Tanaka, T. Misaki, M. Takahashi, G. Watanabe, H. Furuta, T. Doi, et al. Grafts for Left Main Trunk Lesion Using MIDCAB Doughnut on Beating Heart Asian Cardiovasc Thorac Ann, June 1, 2000; 8(2): 114 - 117. [Abstract] [Full Text] [PDF]

				S. Yavuz, M A. Celkan, C. Eris, M. Mavi, T. Turk, O. Tiryakioglu, Y. Ata, V. Koca, and I A. Ozdemir Minimally Invasive Coronary Artery Bypass: Experience in 114 Patients Asian Cardiovasc Thorac Ann, September 1, 1999; 7(3): 177 - 181. [Abstract] [Full Text] [PDF]

				K. Miyaji, R. K. Wolf, and J. B. Flege Jr Minimally invasive direct coronary artery bypass for redo patients Ann. Thorac. Surg., June 1, 1999; 67(6): 1677 - 1681. [Abstract] [Full Text] [PDF]

				J. R. Doty, J. D. Fonger, J. D. Salazar, P. L. Walinsky, and N. W. Salomon EARLY EXPERIENCE WITH MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS GRAFTING WITH THE INTERNAL THORACIC ARTERY J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 873 - 880. [Abstract] [Full Text] [PDF]

				K. Kotoh, G. Watanabe, K. Ueyama, M. Uozaki, M. Suzuki, T. Misaki, M. Wakasugi, and Y. Ito ON-LINE ASSESSMENT OF REGIONAL VENTRICULAR WALL MOTION BY TRANSESOPHAGEAL ECHOCARDIOGRAPHY WITH COLOR KINESIS DURING MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 912 - 917. [Abstract] [Full Text] [PDF]

				K. Miyaji, R. K. Wolf, and J. B. Flege Jr Surgical results of video-assisted minimally invasive direct coronary artery bypass Ann. Thorac. Surg., April 1, 1999; 67(4): 1018 - 1021. [Abstract] [Full Text] [PDF]

				G. Watanabe, T. Misaki, K. Kotoh, A. Yamashita, and K. Ueyama Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries Ann. Thorac. Surg., June 1, 1998; 65(6): 1673 - 1675. [Abstract] [Full Text] [PDF]

This Article 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): Go Watanabe Takuro Misaki Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Watanabe, G. Articles by Ueyama, K. Search for Related Content PubMed PubMed Citation Articles by Watanabe, G. Articles by Ueyama, K.