Minimally Invasive Coronary Artery Bypass Grating Using Bilateral In Situ Internal Thoracic Arteries

Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study

BACKGROUND

This present research was designed for comparing coronary artery disease (CAD) patient outcomes following minimally invasive coronary artery bypass grafting surgery (MICS) or coronary artery bypass grafting (CABG).

METHODS

From 2014-2017, 679 CAD patients underwent MICS (n=281) or CABG (n=398) and were evaluated for the present study. Patient data were analyzed using 1:1 propensity score-matched assessment and a multivariate Cox proportional hazards regression model, and primary study achievements comprised major adverse cardiac and cerebrovascular events (MACCEs), myocardial infarction (MI), cardiac death, heart failure (HF), revascularization, and stroke. The median follow-up period was 2.68 years.

RESULTS

CABG patients exhibited a trend towards higher cumulative overall rates of MACCEs at 2 years (CABG: 6.2% vs. MICS: 3.8%) and 4 years (CABG: 9.3% vs. MICS: 7.6%) [adjusted hazard ratio (HR): 1.33; 95% confidence interval (CI): 0.33-5.39 for CABG vs. MICS; P=0.687], although this difference was not significant. No significant differences in 2- or 4-year cardiac death rates were observed between groups (CABG: 3.5%, 5.6% vs. MICS 2.8%, 2.8%; adjusted HR: 0.23; 95% CI: 0.03-1.81 for CABG vs. MICS; P=0.160). Further, there existed no discrepancies in rates of MI (P=1.000), HF (adjusted HR: 4.76; 95% CI: 0.01-6.40 for CABG vs. MICS; P=0.996), stroke (adjusted HR: 9.58; 95% CI: 0.11-25.24 for CABG vs. MICS; P=0.320), or repeated revascularization (adjusted HR: 1.71; 95% CI: 0.01-7.21 for CABG vs. MICS; P=0.631) when comparing these patient groups. In a multivariable Cox proportional hazards regression analysis, patients that were male (adjusted HR: 5.28; 95% CI: 1.48-18.83; P=0.010) and cases with a history of previous MI epsiodes (adjusted HR: 3.20; 95% CI: 1.09-9.37; P=0.034) were found to be at a higher risk of MACCEs.

CONCLUSIONS

Follow-up data indicated that the MICS and CABG treatments could achieve similar outcomes.

Minimally Invasive Coronary Artery Bypass Grafting with Ultrasonically Skeletonized Internal Thoracic Artery

Objective

This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors’ initial experience.

Methods

From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting.

Results

The patients’ mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality.

Conclusions

Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

Feasibility of bilateral internal thoracic artery harvesting using the da Vinci SP system

PURPOSE

We conducted this study to investigate the feasibility of mobilizing the bilateral internal thoracic arteries (ITAs) using the da Vinci SP through a single intercostal incision and to compare the amount of rib spreading with that required for mini-thoracotomy procedures. We also evaluated the construction of an intrathoracic T-graft anastomosis using existing instrumentation of the SP system.

METHODS

We harvested bilateral ITAs from two male cadavers via a single incision made in the fifth intercostal space using the da Vinci SP. A T-graft end-to-side anastomosis was created in one cadaver.

RESULTS

The bilateral ITAs were harvested in less than 60 min and a T-graft was completed. No additional rib spreading was required. Intraoperative adjustments of the da Vinci SP were necessary to maintain alignment with the surgical targets.

CONCLUSIONS

Bilateral ITA harvest using the da Vinci SP through a single intercostal incision was feasible, with less rib spreading than in mini-thoracotomy procedures. Thus, creating an intrathoracic T-graft with the existing da Vinci SP instruments is possible.

Application of tissue-engineered interventions for coronary artery bypass grafts

Coronary artery bypass graft is one of the extensively conducted procedures to release occlusion in the coronary vessel. Various biological grafts are used for this purpose, superiorly, saphenous vein graft, if unavailable, other vessels in the body, with likewise characteristics are exploited for the purpose. The choice of graft is yet under discovery that could impeccably meet all the requirements. Variation in perioperative and postoperative results have given uneven clinical inferences of these conduits. Alternatively, tissue-engineering is also being applied in this area for clinical improvements. This review underlines some of the commonly used grafts for coronary artery bypass graft and advancements in tissue engineering for this purpose.

Initiation and modification of minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.

Off-Pump Coronary Artery Bypass Grafting with Mini-Sternotomy in the Treatment of Triple-Vessel Coronary Artery Disease

We have developed off-pump coronary artery bypass approach with lower distal mini-sternotomy (TM-OPCAB) for multivessel coronary revascularization. The aim of this retrospective study is to provide evidence for the feasibility and safety of this technique in the treatment of triple-vessel diseases.Two hundred eighty-eight patients with triple-vessel coronary artery disease who underwent TM-OPCAB or standard off-pump coronary artery bypass surgery (S-OPCAB) were included in this study after propensity-score matching. We retrospectively reviewed the clinical data of all patients and compared their demographic data, intra- and perioperative details, as well as short-term and long-term outcomes.TM-OPCAB resulted in significantly shorter periods of time on ventilation (P = 0.0222), shorter postoperative in-hospital stays (P < 0.0001), and lower blood transfusion rates (P = 0.0013) than S-OPCAB. Transit-time flow measurement showed there was no significant difference in postoperative graft patency between both groups. Within the 30-day post-surgical period, no death or occurrence of stroke was observed in patients undergoing TM-OPCAB or S-OPCAB. After an average of 35 months of follow-up, Kaplan-Meier survival analysis indicated that overall survival and the percentage of patients freed from major adverse cardiac and cerebrovascular events were similar between both groups. Additionally, the rate of repeat revascularization was slightly lower in the TM-OPCAB group (1.4%) than in the S-OPCAB group (2.2%), although there was no statistical difference noted.Our findings suggest that TM-OPCAB is technically feasible and safe for use in revascularization procedures in patients with triple-vessel diseases.

Perioperative outcomes of off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries under direct vision†

OBJECTIVES

We previously introduced techniques to harvest and use the right internal thoracic artery in minimally invasive coronary artery bypass grafting (CABG) via a single left thoracotomy for revascularization with bilateral internal thoracic arteries (BITA). We report our short-term outcomes of patients who underwent minimally invasive CABG using BITA and a single internal thoracic artery (SITA).

METHODS

Consecutive patients who underwent minimally invasive CABG using BITA or SITA at a Japanese medical center between February 2012 and December 2015 were reviewed retrospectively. Preoperative, intraoperative and 30-day postoperative outcomes were analysed. Perioperative data for the SITA cohort is presented to provide a context in which the outcomes of the BITA cohort can be evaluated.

RESULTS

A total of 25 and 37 patients underwent BITA and SITA revascularization, respectively. The mean duration of the operation was longer in the BITA group than in the SITA group (265 ± 104 vs 336 ± 73 min). There were no deaths in the BITA group and one death in the SITA group. There were no strokes in either cohort, and new haemodialysis was required in one patient in each group. All BITA grafts were harvested without major complications and were all patent on computed tomography angiograms 1 week following the operations.

CONCLUSIONS

BITA can be safely harvested in a reproducible manner under direct vision via a small left thoracotomy. The potential advantages of minimally invasive CABG using BITA, although yet to be established, include a long-term survival benefit conferred by BITA grafts and elimination of the risk of sternal wound infection, in addition to the established advantages of minimally invasive coronary artery surgery. This approach has the potential for further optimization with hybrid revascularization strategies.

Cardiac surgery using a single thoracic port-current status and future directions

Cardiac surgery is almost universally performed through a median sternotomy, an approach which is painful, unestethical, and prone to life-threatening infections. Minimally invasive cardiac surgery has tried to avoid problems associated with full sternotomy for many years. Recently, uniportal thoracic surgery was shown to be very advantageous when compared to standard thoracotomy and classical video assisted thoracic surgery (VATS). Despite very good results in lung surgery, cardiac surgery through a single thoracic port has rarely been attempted and successfully conducted. The authors present the rational, the technique, and their experience in cardiac single thoracic port surgery (CSTPS).

Minimally invasive coronary artery bypass grafting: a systematic review

To minimize surgical morbidity in coronary artery bypass grafting, minimally invasive cardiac surgery has gained popularity. Minimally invasive coronary artery bypass grafting offers unique advantages compared to conventional off-pump coronary artery bypass or minimally invasive direct coronary artery bypass in that it enables the surgeon to harvest and graft bilateral internal thoracic arteries via a small thoracotomy while being conducted completely off-pump. This review focuses on current evidence behind off-pump coronary artery bypass, multi-arterial revascularization, patient populations that would most benefit from bilateral internal thoracic artery minimally invasive coronary artery bypass grafting, the surgical technique, and early outcomes. By overcoming the perceived inability to utilize bilateral internal thoracic arteries in minimally invasive coronary artery bypass grafting, the new technique further expands the armamentarium of surgeons and cardiologists. Hybrid coronary revascularization with bilateral internal thoracic artery minimally invasive coronary artery bypass grafting further augments the appeal of the next generation of minimally invasive cardiac surgery.

Off-pump minimally invasive coronary artery bypass grafting using the bilateral internal thoracic arteries and the right gastroepiproic artery

We report our initial experience of an off-pump total arterial minimally invasive coronary arterial bypass grafting (MICS CABG) with the use of bilateral internal thoracic arteries (BITA) and the right gastroepiproic artery. A 47-year old male with renal dysfunction secondary to diabetes mellitus was admitted for heart failure due to severe triple-vessel disease. Off-pump MICS CABG with total arterial grafts was elected because the patient refused to undergo median sternotomy due to the strong desire to regain the baseline function promptly. Total arterial grafts were selected to maximize the potential long-term outcome. There were no postoperative complications except temporary dialysis. Postoperative coronary computed tomography revealed the patency of all grafts. Our experience suggests that BITA can be safely harvested under direct vision in MICS CABG. Total arterial graft revascularization with BITA via minimally invasive approach may offer the benefits of MICS CABG while providing the undetermined but potentially superior conduit longevity of arterial grafts.