Eur J Cardiothorac Surg 2001;20:856-857
© 2001 Elsevier Science NL
Thoracoscopy for minimally invasive axillo–coronary artery bypass
Toshiya Ohtsuka,
Hiroshi Kubota,
Noboru Motomura,
Shinichi Takamoto
Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
Received 31 May 2001;
received in revised form 6 July 2001;
accepted 18 July 2001.
Corresponding author. Tel.: +81-3-5800-8654; fax: +81-3-5684-3989
e-mail: ohtsuka-tho{at}h.u-tokyo.ac.jp
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Abstract
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Minimally invasive axillo–coronary artery bypass via a small thoracotomy or a limited sternotomy was performed in five patients. For this approach, videoscopy was used to determine the intrapleural path of each vein graft, which was curved by the expanded lung tissue and had the potential for kinking or distortion. Postoperative angiography confirmed the patency of each graft with no kinking or distortion. Thoracoscopy facilitates this approach, allowing appropriate placement of the vein graft in the chest cavity.
Key Words: Thoracoscopy • Minimally invasive coronary artery bypass • Axillo–coronary artery bypass • Saphenous vein graft
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1. Introduction
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Minimally invasive coronary artery bypass (MICAB) via limited sternotomy or thoracotomy, using a saphenous vein conduit arising from the axillary artery, has been performed in particular circumstances. In this approach, the vein graft passes through the intercostal space, enters the chest cavity and reaches the heart, avoiding interference from pulmonary tissue. We have been using videoscopy for intrapleural positioning of the vein graft when performing this procedure, and here we describe the surgical technique and outcome.
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2. Patients
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Five patients were treated by MICAB using a vein graft which arose from the axillary artery and passed along the intrapleural route. A 66-year-old man with far-advanced gastric cancer, a 72-year-old woman with metastatic skin carcinoma from an undiagnosed origin and an 85-year-old woman with an aneurysm of the aortic arch developed unstable angina and underwent a left axillary to left anterior descending coronary artery (LAD) bypass. A 73-year-old woman with a calcified ascending aorta underwent reoperative MICAB from the left axillary artery to the LAD and a diagonal branch. A 62-year-old woman with a previous coronary artery bypass using a right gastroepiploic artery (GEA) graft in situ underwent a right axillary artery to GEA graft bypass before pancreato–duodenectomy for bile duct cancer in order to preserve the GEA graft flow.
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3. Surgery and outcome
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In each case, general anesthesia was induced using a double-lumen endotracheal tube, and hemipulmonary collapse was allowed. The saphenous vein conduit was harvested from the leg, and a T-shaped graft, consisting of the main trunk and a short branch, was prepared in the patient who required double bypasses to the LAD with a diagonal branch. After systemic infusion of heparin (200 units/kg), the saphenous vein graft was end-to-side anastomosed to the axillary artery via a small infraclavicular incision. A small left anterior thoracotomy was placed at the fourth intercostal space for revascularization of the LAD and the diagonal branch, and a limited lower-half sternotomy was done for the GEA graft [1]. Thereafter, under hemipulmonary collapse, each graft was introduced into the chest cavity through the medial site of the first intercostal space (Fig. 1)
, and advanced to each target artery. A rigid 3.3-mm, 30-degree endoscope (K26007 BA, KARL STORZ, Tuttlingen, Germany) was passed through the limited thoracotomy or sternotomy, and the pathway of the vein graft in the chest cavity was determined while observing the video image obtained through the scope. Then, each anastomosis to the coronary artery or GEA graft was carried out without using cardiopulmonary bypass.
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Fig. 1. Thoracoscopic view of saphenous vein graft (arrowheads) introduced into left thoracic cavity via intercostal space between first (I) and second (II) ribs.
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In each case, the postoperative course was uneventful, and angiography performed 4–7 days after surgery confirmed that each vein graft was patent with no kinking or distortion (Fig. 2)
. There were no deaths or cardiac ischemic events during the 4, 5, 5, 7 and 12 months of follow-up, respectively.
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Fig. 2. Postoperative angiography of saphenous vein graft from left axillary to left anterior descending coronary artery (arrowheads), showing first curve (top arrow) at entry of chest cavity through first intercostal space and second curve (bottom arrow) at medial edge of lung, where vein graft turns and is transferred from anterior to posterior surface of lung tissue.
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4. Comments
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Minimally invasive axillo–coronary artery bypass using a vein graft has been selected for a limited number of patients in whom the internal mammary artery in situ is unavailable or not necessarily required [2–5]. This procedure was used in the present patients who had neoplasm with short life expectancy, aortic arch disease, and previous conventional CAB from a calcified ascending aorta. In one case, a patent GEA graft was rescued by this procedure.
However, compared to the usual aorto–coronary artery bypass, axillo–coronary artery bypass with a vein graft requires a longer distance and its pathway is complicated. Two separate curves are created in the axillo–coronary artery bypass route; the first curve is made at the entry of the chest cavity through the intercostal space, and the second at the medial edge of the lung, where the vein graft turns and is transferred from the anterior to the posterior surface of the lung (Fig. 2). Therefore, there is a potential risk of kinking or distortion at these two particular sites in the vein graft, and such complications may not appear until the lung has expanded and pushed the vein against the chest wall and mediastinum. In our clinical experience, videoscopy was beneficially used. With the aid of the video image, each vein graft was carefully positioned in the tight space between the lung and the surrounding structures, including the chest wall, mediastinum and heart, while in the meantime the lung was being gently and slowly inflated from its collapsed status with manual control by the anesthetist. We employed a rigid scope in the present technique, but a flexible scope might work better in the tight intrapleural space. One additional advantage of videoscopy is that minimal rib retraction can be maintained when inspecting the intrapleural path of the vein graft up to the first intercostal space.
In conclusion, when performing minimally invasive axillo–coronary artery bypass, thoracoscopic guidance makes it possible to determine the intrapleural route of the vein graft from the high intercostal space, eliminating kinking or distortion of the graft and maintaining minimal rib retraction throughout the procedure.
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References
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Bonatti J., Coulson A.S., Bakhshay S.A., Posch L., Sloan T.J. The subclavian and axillary arteries as inflow vessels for coronary artery bypass grafts-combined experience from three cardiac surgery centers. Heart Surg Forum 2000;3:307-312.[Medline]
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Yaryura R., Vardhan R., Springer A.J., Cooley D.A. A 66-year-old man with severe angina and previous coronary artery bypass. Lancet 1997;349:396.[Medline]
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Abstract
1. Introduction
