Integrated minimally invasive direct coronary artery bypass grafting and angioplasty for coronary artery revascularization

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1 Europen Journl of Crdio-thorcic Surgery 22 (2002) Integrted minimlly invsive direct coronry rtery bypss grfting nd ngioplsty for coronry rtery revsculriztion Mrek Cisowski, *, Wlodzimierz Morwski, Jnusz Drzewiecki b, Wojciech Kruczk c, Krzysztof Toczek c, Jroslw Bis, Andrzej Bochenek First Deprtment of Crdic Surgery, Medicl University of Silesi, Ktowice, Polnd b First Deprtment of Crdiology, Medicl University of Silesi, Ktowice, Polnd c Deprtment of Crdio-nesthesiology, Medicl University of Silesi, Ktowice, Polnd Received 25 November 2001; received in revised form 9 April 2002; ccepted 23 April 2002 Abstrct Objective: Minimlly invsive direct coronry rtery bypss (MIDCAB) through the nterolterl minithorcotomy hs become promising therpeutic option in ptients with lesion in left nterior descending rtery (LAD), especilly in multimorbid, elderly nd reoperted ptients with type C or B lesions. To expnd the benefits of MIDCAB concept to ptients with multivessel disese, hybrid myocrdil revsculriztion procedure (HMR) combining surgery of the LAD with interventionl procedures for dditionl coronry lesions hs recently been introduced. Methods: Between Jnury 1999 nd September 2001, 50 ptients (37 mle, 13 femle, men ge 54.8 ^ 20.1 yers) underwent n HMR procedure. MIDCAB with endoscopic left internl thorcic rtery (LITA) hrvesting, followed by percutneous coronry intervention (PCI) for dditionl coronry lesions nd percutneous trnsluminl coronry ngioplsty (PTCA), ws performed in 11 ptients (22%) nd stenting in 39 ptients (78%). Angiogrphic ssessment of grft ptency ws performed in ll ptients during the PCI procedure. The clinicl follow-up period ws 3 32 months. Results: There were no erly nd lte deths. Bseline Cndin Crdiology Society (CCS) clss ws 2.8 ^ 0.7 versus 1.1 ^ 0.9 (P, 0:001) 30 dys fter HMR procedure. There were no mjor cute in hospitl crdic events. Angiogrphic studies showed ptent LIMA-LAD grft in 50 ptients (100%). We showed good qulity of nstomosis in 49 ptients (98%). There ws moderte grft stenosis in one ptient (2%). At long term follow-up, the rte of mjor crdic events ws 12%. Five ptients (10%) developed restenosis fter PCI, nd one ptient (2%) developed significnt stenosis in site of LITA-LAD nstomosis; redo PCI ws performed successfully. Conclusions: The hybrid procedure is sfe nd effective method for complete revsculriztion in selected ptients with double-vessel coronry rtery disese (ptients with type B or C lesions in the proximl LAD). This method llows performnce of complete revsculriztion with minimiztion of surgicl trum. So fr, long-term results of HMR re limited by the results of PCI. q 2002 Elsevier Science B.V. All rights reserved. Keywords: Minimlly invsive coronry rtery bypss; Percutneous trnsluminl coronry ngioplsty; Hybrid myocrdil revsculriztion 1. Introduction Revsculriztion for multivessel coronry rtery disese with left internl thorcic rtery (LITA) nd dditionl vein grfts using crdiopulmonry bypss nd crdioplegic rrest currently represents the stndrd technique in coronry surgery. Minimlly invsive direct coronry rtery bypss (MIDCAB) surgery is becoming widely ccepted s n lterntive method for revsculriztion in single vessel coronry rtery disese, especilly in the proximl segment of left nterior descending rtery (LAD). MIDCAB surgery * Corresponding uthor. ul. Ziolow 47/45, Ktowice, Polnd. Fx: E-mil ddress: cisowskim@yhoo.com (M. Cisowski). through left nterior smll thorcotomy (LAST) ccess is possible to perform in the selected group of ptients. This technique, however, cn be used only in ptients with single-vessel disese concerning LAD or its digonl brnch [1,2]. To expnd the benefits of MIDCAB pproches to ptients with multivessel disese, hybrid myocrdil revsculriztion procedure (HMR) combining surgicl revsculriztion of the LAD with percutneous coronry intervention (PCI) for dditionl coronry lesions is considered to be n ttrctive tretment option for some coronry ptients. The combintion of these two methods enbles to bndon typicl crdic opertion using extrcorporel circultion (ECC), s well s to void the ECC-relted trum /02/$ - see front mtter q 2002 Elsevier Science B.V. All rights reserved. PII: S (02)

2 262 M. Cisowski et l. / Europen Journl of Crdio-thorcic Surgery 22 (2002) nd to improve the tretment nd rehbilittion. It seems to be possible selecting group of ptients, who hve been subjected to coronry rtery bypss grfting (CABG) so fr, nd to qulify them for the less invsive double-step HMR procedure [3 6]. We present the results of our initil studies. 2. Mterils nd methods Between Jnury 1999 nd September 2001 we performed 247 MIDCAB procedures (7% of ll coronry cses). Fifty ptients (37 mle nd 13 femle, men ge 54.8 ^ 20.1 yers) from this group, with double-vessel disese, qulified for combined MIDCAB nd PCI procedure Ptient selection Ptients were qulified for double-stge tretment by consulting crdiologist nd crdic surgeon. Stge I: less invsive opertion video-ssisted MIDCAB to revsculrize the LAD; stge II: PCI of dditionl coronry lesions percuteneous trnsluminl coronry ngioplsty (PTCA) performed in 11 ptients (22%) nd stenting in 39 ptients (78%). The inclusion nd exclusion criteri re summrized in Tble Surgicl technique Hrvesting of the LITA is performed thorcoscopiclly nd the nstomosis between LITA nd LAD is performed on the beting hert through LAST. The technique of thorcoscopic LITA hrvest nd MIDCAB hve been described elsewhere [1 3,7,8], few modifictions hve been introduced. The LITA is dissected from its bed from the superior border of the first rib to the fifth or sixth rib with low-flow crbon dioxide insuffltion using Hrmonic Sclpel (Ethicon Endo-Surgery, Cincinnti, OH) nd with AESOP ssistnce (Computer Motion Inc., Golet, CA). All brnches of the LITA re cogulted with use of the Hrmonic Sclpel. A LAST (4 6 cm) incision is mde through the fourth or fifth intercostl spce. We do not dvocte the routine excision of costl crtilge, becuse the dequte exposure cn be chieved with retrction of the ribs lone. The LAD is incised nd the nstomosis is performed with single 7-0 polypropylene running suture under mechnicl stbiliztion (CTS, Cuperino, CA, nd recently Computer Motion). In ll ptients, relese of cretine kinse nd its myocrdil isoform (CK nd CK-MB, three smples within 24 h) nd Troponin T (preischemic, 8 nd 14 h) ws investigted to evlute the genertion of intropertive ischemi ssocited with the temporry occlusion of the LAD Angioplsty technique Stndrd ccess for PTCA is chieved vi cnnultion of the femorl rtery with the use of 6- or 8-F guiding ctheter. An initil dignostic ngiogrphy is performed in order to ssess the qulity of the LITA-LAD grft nd to confirm the ntomy of the lesions for ngioplsty. The lesions re cnnulted with inch steerble guide wire, followed by blloon dilttion with or without dditionl stenting. Hepriniztion is used throughout the procedure. Once it is completed, the ntipltelet therpy is introduced, comprising spirin when ngioplsty lone ws performed nd spirin in conjunction with ticlopidine when stents were employed. All ptients underwent the PCI fter minimum 24 h recovery following the MIDCAB procedure (men 6.5 ^ 4.6 dys). Angiogrphic ssessment of grft ptency ws performed in ll ptients during PCI procedure. Following end points, showing the effectiveness of revsculriztion were evluted during long-term follow-up (6, 12, 24 months fter HMR): deth, myocrdil infrction (MI), nd reoccurrence of ngin pectoris (mjor dverse coronry event (MACE)) tht required hospitl tretment or repeted revsculriztion in the trget vessel. 3. Results In totl we hve operted on 50 ptients, with complete revsculriztion in ll cses. The preopertive demogrphic dt is summrized in Tble 2. All ptients hd double-vessel disese t initil ngiogrphy (Tble 3). Bseline Cndin Crdiovsculr Society (CCS) clssifiction Tble 1 Inclusion nd exclusion criteri Inclusion criteri Exclusion criteri The LAD lesion with high risk of restenosis fter PTCA (type B or C lesions b ) Buried coronry rtery Restenosis fter PTCA or in-stent restenosis Disseminted rteriosclerosis Dibetic ptients Unstble ngin Young individuls with progressive therosclerosis Acute MI Ptients with comorbidities prone to develop complictions fter crdiopulmonry bypss Decompensted hert filure Redo opertions Significnt rrhythmi Ptient s preference (Jehovh s Witness) Obesity BMI. 30 b BMI, body mss index; LAD, left nterior descending rtery; MI, myocrdil infrction; PTCA, percutneous trnsluminl coronry ngioplsty. Americn College of Crdiology, Americn Hert Assocition

3 M. Cisowski et l. / Europen Journl of Crdio-thorcic Surgery 22 (2002) Tble 2 Ptient demogrphics (n ¼ 50) Tble 4 Erly results (n ¼ 50 ptients): follow-up period 30 dys Vrible Vrible Results Age, men (yers) ^ SD 54.8 ^ 20.1 Sex, mle/femle 37/13 Risk fctors Hypertension 38 (76%) Dibetes mellitus 21 (42%) Hypercholesterolemi 28 (56%) Previous MI in LAD segment 28 (56%) Previous MI in other segments 11 (22%) Men LVEF (%), men ^ SD 52.6 ^ 11 Good (.50%) 933 (66%) Moderte (35 50%) 14 (28%) Poor (,35%) 3 (6%) ws 2.8 ^ 0.7, versus 1.1 ^ 0.9 (P, 0:001) 1 month fter HMR procedure. One ptient (2%) returned to the operting room becuse of bleeding requiring reintervention. After liberl heprin regimen the verge postopertive blood loss ws ^ ml per 24 h. Blood substitutes were dministered in only two ptients (4%). Pleurl effusion ws observed in one ptient (2%) nd ws secondrily drined. In ll ptients nlyzed for intropertive ischemi, ll Troponin T levels rnged below criticl vlue of 0.1 ng/ml. Thus, the temporry LAD occlusion ppered not to be ssocited with significnt myocrdil dmge. Men primry postopertive hospitl sty ws 4.4 ^ 1.7 dys (rnge 3 7 dys). All ptients hd n eventless postopertive course without MI, MACE, coronry reintervention, stroke nd wound-heling complictions following the initil 30 dys of the investigtion. There were no erly deths (Tble 4). Control coronry ngiogrphy ws performed in ll ptients during PCI procedure dys fter surgery (men 6.5 ^ 4.6 dys; Tble 5). We use FitzGibbon s score which is bsed on over 5000 control coronry ngiogrms in order to stndrdize the interprettion of results [9,10]. All LITA-LAD nstomoses were ptent. There ws very good ptency of nstomosis (Grde A) in 49 (98%) ptients (no kinking, conduit stenoses nd open side brnches). Control coronry ngiogrms showed grft stenosis (Grde B) in one ptient (2%); this lesion ws regrded s erly-stge postopertive grft spsm nd ws Tble 3 Angiogrphic chrcteristics of 50 ptients Trget vessels b No. of ptients LAD (type C), RCA (type A) 35 (70%) LAD (type B), RCA (type A) 8 (16%) LAD (type C), OM1 (type A) 7 (14%) b LVEF, left ventriculr ejection frction. OM, obtuse mrginl rtery; RCA, right coronry rtery. Typing ccording to Americn College of Crdiology, Americn Hert Assocition. Endoscopic LITA hrvest time (min) 32.4 ^ 10.6 Length of incision (cm) 5.7 ^ 2.3 Anstomosis time (min) 15.3 ^ 4.5 Postopertive bleeding (ml) ^ Conversion 0 Morbidity 2 (4%) Re-explortion for bleeding 1 (2%) Pneumothorx 1 (2%) No. of ptients needing trnsfusion 2 (4%) Mortlity 0 Periopertive MI 0 Averge CCS score b Before opertion 2.8 ^ 0.7 After opertion 1.1 ^ 0.9 MACE requiring reintervention 0 Hospitl sty, men ^ SD (dys) 4.4 ^ 1.7 CCS, Cndin Crdiovsculr Society; LITA, left internl thorcic rtery; MACE, mjor crdic events. b P, 0:001. left without coronry intervention s the ptient hd no symptoms of ngin (lte control coronry ngiogrphy fter 6 months showed very good grft ptency: Grde A). Long-term follow-up ws completed in 47 (94%) ptients. The verge CCS clss ws 1.6 ^ 0.7. During tht time, six (12.7%) ptients developed new onset ngin (MACE) requiring repeted revsculriztion. One ptient (2.1%) hd severe stenosis t the site of LITA-LAD nstomosis (grde B: rteriosclerosis progression 18 months fter HMR) nd five ptients (10.6%) hd restenosis fter PCI. In ll cses redo PCI with good outcome ws performed. The lte results re shown in Tble Discussion Appliction of less-invsive methods in crdic surgery is still considered s completely new procedure which is tken under thorough investigtion nd often criticl ssessment. In generl, under this mening is hidden gret desire to limit surgicl ccess nd this wy to minimize opertionrelted trum. In crdic surgery one cn understnd by the mening of less invsive the possibility to perform the opertion with- Tble 5 Erly ngiogrphic LITA-LAD grft ssessment in 50 hybrid procedures (2 12 dys) Overll ptency rte 50 (100%) Grde A 49 (98%) Grde B 1 (2%) Grde 0 0 Grde A, excellent grft; Grde B, stenosis reducing distl nstomosis or trunk up to 50% of grfted coronry rtery; Grde 0, occlusion.

4 264 M. Cisowski et l. / Europen Journl of Crdio-thorcic Surgery 22 (2002) Tble 6 Long-term follow-up (n ¼ 47 (94%) ptients) Vrible Months fter HMR Totl /50 pts 39/50 pts 11/50 pts Mortlity MI Stroke MACE (12.7%) Overll rte of reintervention (12.7%) After PCI (10.6%) restenosis fter PTCA (6.3%) in-stent restenosis (4.3%) After surgery stenosis of the nstomosis (2.1%) HMR, hybrid myocrdil revsculriztion procedure; pts, ptients. out the use of extrcorporel circultion, which hs its own dvntges (e.g. operting on rrested or open hert), s well s drwbcks such s risk of serious complictions which re due to the use of ECC pplinces. The limited operting ccess hs inferior significnce; however, one cnnot neglect spects such s cosmetic effect, less pin, s well s better rehbilittion nd quicker return to norml life [1,8,11,12]. Crdiologists performing coronroplsty procedure offer less invsive nd pinless methods of myocrdil revsculriztion. Other dvntges re lower costs of these revsculriztion procedures nd of further phrmcologicl tretment [11]. Crdiologists nd crdic surgeons disstisfied with long-term results of coronroplsty hve begun to clculte which method of tretment would be the best option for myocrdil revsculriztion. The rte of 1-yer restenosis fter ngioplsty is estimted t 40% nd t 15 20% in cses of stent implnttion [11,13 15]. In contrst, it is known tht implnttion of LITA to LAD ensures 96% ptency rte 10 yers fter opertion [16]. The Coronry Artery Surgery Study (CASS) nd other investigtions hve shown tht the use of the LITA s bypss conduit in coronry surgery improves the survivl rtes in the longterm follow-up (10 15 yers) [16 18]. There re multiple rndomized comprble trils which re conducted to evlute the efficiency of both methods. These two methods undoubtedly bring some limittions. In the cse of ngioplsty, it is very risky or even impossible to be crried out in ptients with multiple stenosis or with occlusion in proximl segment of LAD [11,13 15]. A limittion to less invsive procedures using mini-ccess is the possibility of revsculriztion of only one rtery [1,2,12]. The only purpose ws to extend the indictions nd to enlrge the group of ptients who cn void conducting of trditionl CABG opertions using ECC. Besides, it seems tht both techniques supplement ech other nd llow performnce of complete revsculriztion in tht group of ptients with multivessel coronry disese in whom ppliction of ech of these methods seprtely would not be effective. Our preliminry report is the best exmple of new chllenges. According to clssicl indictions, our ptients should qulify for routine crdic opertion. A less invsive crdic opertion provides us with the possibility of performing sfe nd precise grfting using the thorcic rtery. Appliction of videoscopic hrvesting of LIMA nd stbilizer for better immobiliztion of the operting field improved the sfety stndrds nd precision of crdic surgery [2,7,8,19,20]. It seems tht we now fce some revlutions nd inventions of new concepts concerning the choice of coronry disese tretment. The pproch of new surgicl, less invsive methods of tretment gives us the opportunity to look for new solutions in tht field. One cn expect tht criteri for such procedures will become less strict. We know tht so-clled off-pump opertions re prticulrly beneficil in ptients with severely impired left ventricle, elderly people with disseminted therosclerosis of the ort nd other rteries, nd in ptients with severe comorbidities. A stedy dvnce in interventionl crdiology (e.g. new technology of stent production: ELUT coronry stent) iming for improvement of long-term results of coronoplsty nd stenting, comes to one conclusion: crdiologists s well s crdic surgeons should combine their desires to improve the sfety nd comfort stndrds of their ptients. The hybrid procedures re sfe nd effective methods for complete revsculriztion in selected ptients with doublevessel coronry rtery disese (ptients with type C lesion in the proximl LAD). This method llows performnce of complete revsculriztion with minimiztion of surgicl trum. So fr, long-term results of HMR re limited by the results of PCI. References [1] Ntf P, Lim L, Regn M, Rmdn R, Jult F, Pvie A, Gndjbkhch I. Video-ssisted coronry bypss surgery: clinicl results. J Crd Surg 1996;11: [2] Ntf P, Lim L, Regn M, Benrim S, Rmdn R, Pvie A, Gndjbkhch I. Thorcoscopic internl mmmry rtery hrvesting: Technicl considertions. Ann Thorc Surg 1997;63: [3] Cisowski M, Gerber W, Drzewiecki J, Bochenek A. A hybrid procedure for myocrdil revsculriztion. Pol Hert J 1999;51: [4] Diegeler A, Spyrntis N, Mtin R, Flk V, Hmbrecht R, Autchbch R, Mohr FW, Schuler G. The revivl of surgicl tretment for isolted proximl high grde LAD lesion by minimlly invsive coronry rtery bypss grfting. Eur J Crdiothorc Surg 2000;17: [5] Lloyd C, Clfiore A, Wilde P, Ascione R, Plosci L, Monk Ch, Angelini G. Integrted left nterior smll thorcotomy nd ngioplsty coronry revsculriztion. Ann Thorc Surg 1999;68: [6] Wittwer T, Cremer J, Boonstr P, Grndjen J, Mrini M, Mügge A, Drexler H, Heijer P, Leitner ER, Hepp A, Wehr M, Hverich A. Myocrdil hybrid revsculristion with minimlly direct coronry rtery bypss grfting combined with coronry ngioplsty: preliminry results of multicenter study. Hert 2000;84:58 63.

5 M. Cisowski et l. / Europen Journl of Crdio-thorcic Surgery 22 (2002) [7] Benetii F, Bllester C, Sni G, Boonstr PW, Grndjen J. Videossisted coronry bypss surgery. J Crd Surg 1995;10: [8] Benetti F, Mrini MA, Sni G, Boonstr PW, Grndjen JG, Giomrelli P, Toscno M. Video-ssisted minimlly invsive coronry opertion without crdiopulmonry bypss: multicenter study. J Thorc Crdiovsc Surg 1996;112: [9] FitzGibbon G, Kfk H, Lech A, Keon WJ, Hooper GD, Burton JR. Coronry bypss grft fte nd ptient outcome: ngiogrphic followup of 5065 grfts relted to survivl nd reopertion in 1388 ptients during 25 yers. J Am Coll Crdiol 1996;28: [10] Mck MJ, Mgovern JA, Acuff TA, Lnderneu RJ, Tennison DM, Tinnermn EJ, Osborne JA. Results of grft ptency by immedite ngiogrphy in minimlly invsive coronry rtery surgery. Ann Thorc Surg 1999;688: [11] Loop FD. Coronry rtery surgery: the end of the beginning. Eur J Crdiothorc Surg 1998;14: [12] Westby S, Benetti F. Less invsive coronry surgery: consensus from the Oxford meeting. Ann Thorc Surg 1996;62: [13] Mrini MA, Boonstr PW, Grndjen JG, Peels JOJ, Monnink SHJ, den Heijr P, Crijns HJGM. Minimlly invsive coronry bypss grfting versus coronry ngioplsty for isolted type C stenosis of the nterior descending rtery. J Thorc Crdiovsc Surg 1997;114: [14] Prk SW, Lee CW, Hong MK, Kim JJ, Cho GY, Nh DY, Prk SJ. Rndomized comprison of coronry stenting with optiml blloon ngioplsty for long-term tretment of lesions in smll coronry rteries. Eur Hert J 2000;21: [15] Serruys PW, Hmburger JN, Koolen JJ, Fjdet J, Hude M, Klues H, Sebr-Gomes R, Corcos T, Hmm C, Pizzuli L, Meier B, Mthey D, Fleck E, Teymns Y, Mlkert R, Teunissen Y, Simon R. Totl occlusion tril with ngioplsty by using lser guidewire. Eur Hert J 2000;21: [16] Loop FD, Lytle BW, Cosgrove DM. Influence on the internl mmmry rtery grft of 10 yer survivl nd other crdic events. N Engl J Med 1986;314:1 6. [17] Cmeron A, Dvis KB, Green G, Schff HV. Coronry bypss surgery with internl thorcic rtery grfts. Effects on survivl over 15-yer period. N Engl J Med 1996;334: [18] Loop FD. Internl thorcic rtery grfts. Biologiclly better mmmry rteries (Editoril). N Engl J Med 1996;334: [19] Clfiore A, DiGimmrco G, Teodori G, Bosco G, Dnnuzio E, Brsotti A, Mddestr N, Plosci L, Vitoll G, Scirr A, Fino C, Contini M. Left nterior descending coronry rtery grfting vi left nterior smll thorcotomy without crdiopulmonry bypss. Ann Thorc Surg 1996;61: [20] Subrmnin V, Stelzer P. Clinicl experience with minimlly invsive coronry rtery bypss grfting. Eur J Crdiothorc Surg 1996;10: