Coronary artery bypass grafting traditionally is carried

Minimal Access Surgical Techniques in Coronary Artery Bypass Grafting for Triple-Vessel Disease Pyng Jing Lin, MD, Chau-Hsiung Chang, MD, Jaw-Ji Chu, MD, Hui-Ping Liu, MD, Feng-Chun Tsai, MD, Fen-Chiung Lin, MD, Cheng-Wen Chiang, MD, and Peter P. C. Tan, MD Division of Thoracic and Cardiovascular Surgery, Division of Cardiology, and Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung Medical College, Taipei, Taiwan Background. Minimal access surgical techniques in coronary artery bypass grafting have been used mainly in the management of single-vessel disease. Methods. Fifteen patients, 11 men and 4 women with a mean age of 64.1 years (range, 35.7 to 78.0 years), underwent operation for triple-vessel disease using minimal access techniques. The procedures were performed through a limited left parasternal thoracotomy using femorofemoral extracorporeal circulation. The myocardium was protected by the antegrade infusion of cold blood cardioplegic solution while the aorta was crossclamped. Results. Under direct vision, the left saphenous vein grafts were connected sequentially to the diagonal branch, obtuse marginal branch, and posterior descending branch, and the left internal thoracic artery graft was anastomosed to the left anterior descending artery in each patient. The mean aortic cross-clamp time was 86 17 minutes (range, 67 to 125 minutes). The mean duration of extracorporeal circulation was 112 22 minutes (range, 82 to 162 minutes). The postoperative course was uneventful in all patients. Follow-up was complete in all patients at a mean of 7.4 months (range, 6.0 to 8.5 months), and there were no late deaths or angina. Coronary angiography in 8 patients showed patent grafts. Conclusions. Our experience demonstrates that minimal access surgical techniques in coronary artery bypass grafting are technically feasible and may be an alternative approach in the surgical revascularization of triplevessel disease. (Ann Thorac Surg 1998;65:407 12) 1998 by The Society of Thoracic Surgeons Coronary artery bypass grafting traditionally is carried out with a median sternotomy, extracorporeal circulation, aortic cross-clamping, the infusion of cardioplegic solution, and multiple grafting with left internal thoracic artery (LITA) and saphenous vein grafts. However, the poor cosmetic effect and possible complications of median sternotomy occasionally are troublesome. The concept of minimally invasive surgical techniques has been introduced recently in the field of cardiac surgery [1 11]. These operations have been performed through a minithoracotomy with or without the guidance of a video-assisted endoscope. The minimally invasive nature of these procedures can lessen incisional pain, minimize incisional length, enhance functional recovery, and shorten the hospital stay. Minimal access procedures for the surgical revascularization of coronary artery disease, performed through a limited left anterior thoracotomy [3, 7, 12, 13] or a parasternal incision [14] with or without extracorporeal circulation, recently have been used in patients with single- or double-vessel disease. However, these techniques rarely are used in patients with triple-vessel Accepted for publication July 28, 1997. Address reprint requests to Dr Lin, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199, Tun-Hwa North Rd, Taipei, Taiwan 10591. disease. In this report, we review our initial results using minimal access techniques for coronary artery bypass grafting in patients with triple-vessel disease. Patients and Methods Patients Fifteen patients, 11 men and 4 women with a mean age of 64.1 11.0 years (range, 35.7 to 78 years), underwent operation for triple-vessel coronary artery disease using minimally invasive surgical techniques (Table 1). Patients with severe aortoiliac occlusive disease or severe atherosclerotic disease of the ascending aorta were excluded. Myocardial infarction had occurred in 10 patients. Coronary angiographic examination showed left main coronary artery lesions in 7 patients and triple vessel disease in all patients. Percutaneous transluminal coronary angioplasty had been performed in 2 patients. The mean left ventricular ejection fraction was 0.57 0.16 (range, 0.34 to 0.83). A smoking history was noted in 8 patients (53%). Diabetes mellitus was diagnosed in 5 patients (33%). Hypertension was observed in 5 patients (33%) and hypercholesterolemia in 8 patients (53%). A previous stroke had occurred in 4 patients (27%). Written consent was obtained from the patients and their family members before the operation. 1998 by The Society of Thoracic Surgeons 0003-4975/98/$19.00 Published by Elsevier Science Inc PII S0003-4975(97)01153-3

408 LIN ET AL Ann Thorac Surg MINIMAL ACCESS FOR CABG 1998;65:407 12 Table 1. Patient Information Parameter Value Age (y) a 64.1 11.0 (35.7 78) Previous myocardial infarction b 10 (67) Triple-vessel disease b 15 (100) Left main lesion b 7 (47) PTCA b 2 (13) LVEF a 0.57 0.16 (0.34 0.83) a Values are means plus or minus standard deviation with range given in parentheses; b Values are absolute numbers with percentages given in parentheses. LVEF left ventricular ejection fraction; PTCA percutaneous transluminal coronary angioplasty. Surgical Technique After the induction of general anesthesia, transesophageal echocardiographic monitoring was set up and the regional wall motion abnormality was identified. The patient was placed in a supine position with the left groin exposed. A limited (10- to 12-cm) left anterior parasternal thoracotomy was performed (Fig 1) and the costal cartilages of the third and fourth ribs were resected. The costal cartilages of the second and fifth ribs were not divided. Care was taken not to damage the underlying LITA. The LITA was identified beside the sternal border and was isolated from the first to the fifth intercostal spaces under direct vision. In the meantime, a greater saphenous vein graft was harvested from the lower limb. The left common femoral artery and vein then were isolated. Systemic heparinization (250 U/kg) was accomplished at this point. The ascending aorta was isolated from the main and the right pulmonary arteries and was encircled with an umbilical tape. A partial clamp (Kay Clamp; Pilling, Fort Washington, PA) then was applied on the proximal part of the ascending aorta, which was pulled into the operative field by the umbilical tape (Fig 2A). Proximal anastomosis of the saphenous vein to the ascending aorta was performed under direct vision (Fig 2B). A doublelumen aortic root cannula (DLP, Inc, Grand Rapids, MI) then was inserted at the aortic root for delivery of the cardioplegic solution and venting of the left ventricle (Fig 2C). Extracorporeal circulation was established through cannulation of the left femoral artery and the left femoral vein. A membranous oxygenator (Maxima Plus oxygenation system; Medtronic Inc, Cardiopulmonary Division, Anaheim, CA) was used. Systemic hypothermia (rectal temperature 27.6 0.9 C) began immediately after the start of extracorporeal circulation. Topical cooling of the heart was not used. The aorta was cross-clamped at the distal part of the ascending aorta (Fig 2D). The myocardium was protected by cold blood cardioplegic solution with a potassium ion concentration of 20 mmol/l, which was infused into the aortic root at this point and after the completion of each distal anastomosis. The cardioplegic solution was delivered to the myocardium through the native coronary arteries and the grafted saphenous vein. The heart soon was arrested and cooled, and was decompressed by venting through the aortic root cannula. The saphenous vein (Fig 3B) was grafted sequentially to the diagonal branch (Fig 3C), obtuse marginal branch, and posterior descending branch (Fig 3D) with a running suture under direct vision. The LITA then was anastomosed to the left anterior descending artery while rewarming was begun (Fig 3A). The anastomotic areas were steady and clear because of the cardioplegic arrest and aortic cross-clamping, making performance of the anastomosis easy and smooth. After the completion of all the anastomoses, warm blood cardioplegia was infused into the aortic root. The clamp on the LITA and the aortic cross-clamp then were removed. Sinus rhythm returned spontaneously and cardioversion was unnecessary in all patients. Extracorporeal circulation was terminated after rewarming of the patients. The pericardium was not closed. A small dose of sodium nitroprusside was infused. Cardiotonic drugs were not used. Intraaortic balloon counterpulsation was not used during or after the operation in any of the patients. Temporary pacemaker wires and pleural drainage were set up routinely. Hemostasis and closure of the incisions were achieved easily. Results Four distal anastomoses were performed in each patient. Conversion to median sternotomy was not necessary in any patient. The mean aortic cross-clamp time was 86 17 minutes (range, 67 to 125 minutes). The mean duration of extracorporeal circulation was 112 22 minutes (range, 82 to 162 minutes) (Table 2). Transesophageal echocardiography performed after the termination of extracorporeal circulation showed improvement of the regional wall motion abnormality from the original level of impairment in all patients. All patients regained con- Fig 1. Incision for minimal access coronary artery bypass grafting.

Ann Thorac Surg LIN ET AL 1998;65:407 12 MINIMAL ACCESS FOR CABG 409 Fig 2. Manipulation of the ascending aorta. (A) A partial clamp (arrows) was applied on the proximal part of the ascending aorta (arrowhead), which was pulled into the operative field by the umbilical tape. (B) Proximal anastomosis (double arrowhead) of the saphenous vein graft (arrow) to the ascending aorta (arrowhead) was performed under direct vision. (C) A double-lumen aortic root cannula (double arrowhead) was inserted at the aortic root (arrow) for delivery of the cardioplegic solution and venting of the left ventricle. (D) The aorta was cross-clamped (arrow) at the distal part of the ascending aorta (arrowhead). The proximal anastomosis (double arrowhead) of the saphenous vein graft also was noted. sciousness without any neurologic deficits shortly after arriving at the intensive care unit. There were no cases of postoperative low cardiac output. The endotracheal tube was removed on the operative night. There were no hospital deaths, perioperative myocardial infarctions, or wound infections. Paradoxical movement was found on a small area of the anterior chest wall where the costal cartilages were removed. However, the thoracic cages were stable without respiratory compromise in all patients. The mean postoperative hospital stay was 4.2 0.5 days (range, 4 to 6 days). Follow-up was complete for all patients at a mean of 7.4 months (range, 6 to 8.5 months), with no cases of angina, lower limb vascular complications, or late death. Eight patients underwent coronary angiography, which showed patent grafts without stenosis (Fig 4). The proximal branches of the LITA were not observed. Transthoracic echocardiographic examinations showed adequate left ventricular performance, with a mean ejection fraction of 0.68 0.10 (range, 0.49 to 0.80). All the patients were found to be in New York Heart Association functional class 1 or 2 (mean, 1.2). All the patients were satisfied with the cosmetic results of healing of the limited parasternal incision. The paradoxical movement of the left anterior chest wall disappeared during the follow-up period. Comment In this study, 15 patients underwent successful operation for triple-vessel coronary artery disease using minimal access surgical techniques. Complete revascularization with four distal anastomoses was performed using the LITA and the saphenous vein through a limited left anterior thoracotomy under femorofemoral extracorporeal circulation with aortic cross-clamping and cold blood cardioplegic arrest. This indicates that minimal access surgical techniques are technically feasible and may be a good alternative in the surgical correction of triple-vessel coronary artery disease. Traditionally, standard coronary artery bypass grafting has required a long and painful median sternotomy incision. The results generally are excellent. However,

410 LIN ET AL Ann Thorac Surg MINIMAL ACCESS FOR CABG 1998;65:407 12 Fig 3. Graft anastomosis to the coronary arteries with the heart arrested and vented. (A) The left internal thoracic artery (arrowhead) was grafted to the left anterior descending artery (arrow). (B) The proximal part of the sequential saphenous vein graft (arrowhead). (C) The saphenous vein (arrow) was connected to the diagonal branch (arrowhead) sequentially. (D) The saphenous vein (arrow) was grafted to the obtuse marginal branch (arrowhead) and the posterior descending branch (double arrowhead) sequentially. the incisional pain, poor cosmetic effect, and possible complications of median sternotomy occasionally are troublesome. From our experience with laparoscopic and thoracoscopic operations, we know that minimal access techniques can be used to replace well-established, safe, and minimally complicated standard procedures such as cholecystectomy for gallstones or bulla resection for pneumothorax, without compromising efficacy and Table 2. Operative Data Parameter Value a Aortic cross-clamp time (min) 86 17 (67 125) Duration of extracorporeal 112 22 (83 162) circulation (min) Rectal temperature ( C) b 27.6 0.9 (26 29) Postoperative hospital stay (days) 4.2 0.5 (4 6) Follow-up (mo) 7.4 0.9 (6.0 8.5) a Values are mean plus or minus standard deviation with a range given in parentheses. b Lowest rectal temperature during extracorporeal circulation. safety [15]. Minimal access surgical techniques provide expediency, safety, minimal discomfort, reduced postoperative pain, quick functional recuperation, excellent cosmetic healing, a shortened hospital stay, and cost savings [15]. In our preliminary experience with 15 such procedures, there were no operative deaths, no wound or lower limb vascular complications, and no cases of neurologic deficit. Both the incision length and the postoperative hospital stay were significantly shorter, and all the patients were satisfied with the cosmetic results of healing. These findings indicate that minimal access surgical techniques are safe and effective. There are several ways to perform coronary artery bypass grafting using minimal access techniques. An LITA graft can be connected to the left anterior descending artery with the heart beating and without the use of extracorporeal circulation through a limited left anterior thoracotomy, with good short-term results [3, 12, 13]. This technique is used mainly in patients who have single or double vessel coronary artery disease [13]. Coronary artery bypass grafting also can be performed through port access with a left anterior minithoracotomy under

Ann Thorac Surg LIN ET AL 1998;65:407 12 MINIMAL ACCESS FOR CABG 411 Fig 4. Coronary angiography showing a patent left internal thoracic artery graft connected to the left anterior descending artery. endovascular cardiopulmonary bypass with an endoscopic aortic clamp and cardioplegic arrest, with good short-term results [16 18]. This approach provides prompt cardiac arrest, adequate cardiac decompression, and a clear and bloodless field. However, this approach requires multiple vascular access sites and the availability of fluoroscopic equipment in the operating room. Classically, coronary artery bypass grafting has been performed using aortic cross-clamping, cardioplegic arrest, and multiple grafts involving the LITA and the saphenous vein. This method is familiar to most cardiac surgeons. In our experience, these techniques also can be used for multiple graft procedures in patients with triplevessel coronary artery disease by applying the minimal access surgical techniques described in this article. Proximal anastomosis of the saphenous vein to the ascending aorta can be performed easily by encircling the ascending aorta, pulling it into the operative field, and partially clamping it. The ascending aorta also can be crossclamped and infused with cold blood cardioplegic solution through the parasternal incision. The saphenous vein also can provide an additional route for delivery of the cold blood cardioplegic solution to the myocardium during aortic cross-clamping. In this way, prompt cardiac arrest, good myocardial protection, and a steady and clear anastomotic field can be achieved. The LITA and saphenous vein could be grafted to the stenotic coronary arteries to accomplish a complete revascularization. These techniques are very similar to those that all cardiac surgeons currently perform through a median sternotomy for multiple grafts in patients with triple vessel coronary artery disease, which is the primary surgical indication of coronary artery disease today. In cardiac operations, cardiopulmonary bypass can be performed through cannulation of the femoral artery and vein [19, 20], with excellent results. In minimally invasive cardiac operations, simple femorofemoral bypass also produces satisfactory perfusion of all vital organs, including the brain [4 10, 16 18]. In our series, there were no cases of organ failure after operation, and all patients regained consciousness promptly, indicating adequate tissue perfusion during femorofemoral extracorporeal circulation. The major advantages of minimal access operations in our series are the avoidance of sternotomy and the ability to perform multiple grafts for complete revascularization (four distal anastomoses in each patient). The minimally invasive nature of these procedures reduces the incidence of postoperative mediastinitis and wound pain to a minimum [21]. There were no wound infections or cases of mediastinitis in our patients. All our patients were satisfied with the cosmetic effect of the limited incision. The postoperative hospital stay was shorter in this series (mean, 4.2 days) than it is with uncomplicated coronary artery bypass grafting performed through a median sternotomy (mean, 8.2 days) [7], as has been the experience of other authors [3, 12, 13]. However, the general application of this approach as a routine procedure requires further long-term analysis of a larger series in which the patients are compared with those who undergo a traditional median sternotomy. In conclusion, minimal access surgical techniques can be carried out safely, easily, and effectively, and they may be a good alternative for multiple grafts in patients with triple-vessel coronary artery disease. References 1. 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