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Eur J Cardiothorac Surg 2002;22:261-265
© 2002 Elsevier Science NL

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

Marek Cisowskia*, Wlodzimierz Morawskia, Janusz Drzewieckib, Wojciech Kruczakc, Krzysztof Toczekc, Jaroslaw Bisa, Andrzej Bocheneka

a First Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
b First Department of Cardiology, Medical University of Silesia, Katowice, Poland
c Department of Cardio-anesthesiology, Medical University of Silesia, Katowice, Poland

Received 25 November 2001; received in revised form 9 April 2002; accepted 23 April 2002.

* Corresponding author. ul. Ziolowa 47/45, 40-635 Katowice, Poland. Fax:+48-32-253000
e-mail: cisowskim{at}yahoo.com


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Minimally invasive direct coronary artery bypass (MIDCAB) through the anterolateral minithoracotomy has become a promising therapeutic option in patients with lesion in left anterior descending artery (LAD), especially in multimorbid, elderly and reoperated patients with type C or B lesions. To expand the benefits of MIDCAB concept to patients with multivessel disease, a hybrid myocardial revascularization procedure (HMR) combining surgery of the LAD with interventional procedures for additional coronary lesions has recently been introduced. Methods: Between January 1999 and September 2001, 50 patients (37 male, 13 female, mean age 54.8±20.1 years) underwent an HMR procedure. MIDCAB with endoscopic left internal thoracic artery (LITA) harvesting, followed by percutaneous coronary intervention (PCI) for additional coronary lesions and percutaneous transluminal coronary angioplasty (PTCA), was performed in 11 patients (22%) and stenting in 39 patients (78%). Angiographic assessment of graft patency was performed in all patients during the PCI procedure. The clinical follow-up period was 3–32 months. Results: There were no early and late deaths. Baseline Canadian Cardiology Society (CCS) class was 2.8±0.7 versus 1.1±0.9 (P<0.001) 30 days after HMR procedure. There were no major acute in–hospital cardiac events. Angiographic studies showed patent LIMA-LAD graft in 50 patients (100%). We showed good quality of anastomosis in 49 patients (98%). There was a moderate graft stenosis in one patient (2%). At long term follow-up, the rate of major cardiac events was 12%. Five patients (10%) developed restenosis after PCI, and one patient (2%) developed significant stenosis in site of LITA-LAD anastomosis; redo PCI was performed successfully. Conclusions: The hybrid procedure is a safe and effective method for complete revascularization in selected patients with double-vessel coronary artery disease (patients with type B or C lesions in the proximal LAD). This method allows performance of complete revascularization with minimization of surgical trauma. So far, long-term results of HMR are limited by the results of PCI.

Key Words: Minimally invasive coronary artery bypass • Percutaneous transluminal coronary angioplasty • Hybrid myocardial revascularization


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Revascularization for multivessel coronary artery disease with left internal thoracic artery (LITA) and additional vein grafts using cardiopulmonary bypass and cardioplegic arrest currently represents the standard technique in coronary surgery.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery is becoming widely accepted as an alternative method for revascularization in single vessel coronary artery disease, especially in the proximal segment of left anterior descending artery (LAD). MIDCAB surgery through a left anterior small thoracotomy (LAST) access is possible to perform in the selected group of patients. This technique, however, can be used only in patients with single-vessel disease concerning LAD or its diagonal branch [1,2].

To expand the benefits of MIDCAB approaches to patients with multivessel disease, a hybrid myocardial revascularization procedure (HMR) combining surgical revascularization of the LAD with percutaneous coronary intervention (PCI) for additional coronary lesions is considered to be an attractive treatment option for some coronary patients.

The combination of these two methods enables to abandon a typical cardiac operation using extracorporeal circulation (ECC), as well as to avoid the ECC-related trauma and to improve the treatment and rehabilitation. It seems to be possible selecting a group of patients, who have been subjected to coronary artery bypass grafting (CABG) so far, and to qualify them for the less invasive double-step HMR procedure [3–6]. We present the results of our initial studies.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Between January 1999 and September 2001 we performed 247 MIDCAB procedures (7% of all coronary cases). Fifty patients (37 male and 13 female, mean age 54.8±20.1 years) from this group, with double-vessel disease, qualified for a combined MIDCAB and PCI procedure.

2.1. Patient selection
Patients were qualified for double-stage treatment by consulting a cardiologist and cardiac surgeon. Stage I: less invasive operation – video-assisted MIDCAB to revascularize the LAD; stage II: PCI of additional coronary lesions – percuteneous transluminal coronary angioplasty (PTCA) performed in 11 patients (22%) and stenting in 39 patients (78%). The inclusion and exclusion criteria are summarized in Table 1.


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  		Table 1. Inclusion and exclusion criteriaa

 
2.2. Surgical technique
Harvesting of the LITA is performed thoracoscopically and the anastomosis between LITA and LAD is performed on the beating heart through a LAST. The technique of thoracoscopic LITA harvest and MIDCAB have been described elsewhere [1–3,7,8], a few modifications have 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 carbon dioxide insufflation using a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) and with AESOP assistance (Computer Motion Inc., Goleta, CA). All branches of the LITA are coagulated with use of the Harmonic Scalpel.

A LAST (4–6 cm) incision is made through the fourth or fifth intercostal space. We do not advocate the routine excision of costal cartilage, because the adequate exposure can be achieved with retraction of the ribs alone. The LAD is incised and the anastomosis is performed with a single 7-0 polypropylene running suture under mechanical stabilization (CTS, Cuperino, CA, and recently Computer Motion). In all patients, release of creatine kinase and its myocardial isoform (CK and CK-MB, three samples within 24 h) and Troponin T (preischemic, 8 and 14 h) was investigated to evaluate the generation of intraoperative ischemia associated with the temporary occlusion of the LAD.

2.3. Angioplasty technique
Standard access for PTCA is achieved via cannulation of the femoral artery with the use of a 6- or 8-F guiding catheter. An initial diagnostic angiography is performed in order to assess the quality of the LITA-LAD graft and to confirm the anatomy of the lesions for angioplasty. The lesions are cannulated with a 0.014-inch steerable guide wire, followed by balloon dilatation with or without additional stenting. Heparinization is used throughout the procedure. Once it is completed, the antiplatelet therapy is introduced, comprising aspirin when angioplasty alone was performed and aspirin in conjunction with ticlopidine when stents were employed.

All patients underwent the PCI after minimum 24 h recovery following the MIDCAB procedure (mean 6.5±4.6 days). Angiographic assessment of graft patency was performed in all patients during PCI procedure.

Following end points, showing the effectiveness of revascularization were evaluated during long-term follow-up (6, 12, 24 months after HMR): death, myocardial infarction (MI), and reoccurrence of angina pectoris (major adverse coronary event (MACE)) that required hospital treatment or repeated revascularization in the target vessel.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
In total we have operated on 50 patients, with complete revascularization in all cases. The preoperative demographic data is summarized in Table 2. All patients had double-vessel disease at initial angiography (Table 3). Baseline Canadian Cardiovascular Society (CCS) classification was 2.8±0.7, versus 1.1±0.9 (P<0.001) 1 month after HMR procedure. One patient (2%) returned to the operating room because of bleeding requiring reintervention. After liberal heparin regimen the average postoperative blood loss was 426.5±312.6 ml per 24 h.


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  		Table 2. Patient demographics (n=50)a

 

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  		Table 3. Angiographic characteristics of 50 patientsa

 
Blood substitutes were administered in only two patients (4%). Pleural effusion was observed in one patient (2%) and was secondarily drained. In all patients analyzed for intraoperative ischemia, all Troponin T levels ranged below a critical value of 0.1 ng/ml. Thus, the temporary LAD occlusion appeared not to be associated with a significant myocardial damage. Mean primary postoperative hospital stay was 4.4±1.7 days (range 3–7 days). All patients had an eventless postoperative course without MI, MACE, coronary reintervention, stroke and wound-healing complications following the initial 30 days of the investigation. There were no early deaths (Table 4).


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  		Table 4. Early results (n=50 patients): follow-up period 30 daysa

 
Control coronary angiography was performed in all patients during PCI procedure - 2–12 days after surgery (mean 6.5±4.6 days; Table 5). We use FitzGibbon's score which is based on over 5000 control coronary angiograms in order to standardize the interpretation of results [9,10]. All LITA-LAD anastomoses were patent. There was a very good patency of anastomosis (Grade A) in 49 (98%) patients (no kinking, conduit stenoses and open side branches). Control coronary angiograms showed graft stenosis (Grade B) in one patient (2%); this lesion was regarded as early-stage postoperative graft spasm and was left without coronary intervention as the patient had no symptoms of angina (late control coronary angiography after 6 months showed very good graft patency: Grade A).


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  		Table 5. Early angiographic LITA-LAD graft assessment in 50 hybrid procedures (2–12 days)

 
Long-term follow-up was completed in 47 (94%) patients. The average CCS class was 1.6±0.7. During that time, six (12.7%) patients developed new onset angina (MACE) requiring repeated revascularization. One patient (2.1%) had severe stenosis at the site of LITA-LAD anastomosis (grade B: arteriosclerosis progression 18 months after HMR) and five patients (10.6%) had restenosis after PCI. In all cases redo PCI with a good outcome was performed. The late results are shown in Table 6.


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  		Table 6. Long-term follow-up (n=47 (94%) patients)a

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Application of less-invasive methods in cardiac surgery is still considered as a completely new procedure which is taken under thorough investigation and often critical assessment. In general, under this meaning is hidden a great desire to limit surgical access and this way to minimize operation-related trauma.

In cardiac surgery one can understand by the meaning of ‘less invasive’ the possibility to perform the operation without the use of extracorporeal circulation, which has its own advantages (e.g. operating on ‘arrested’ or open heart), as well as drawbacks such as risk of serious complications which are due to the use of ECC appliances. The limited operating access has inferior significance; however, one cannot neglect aspects such as cosmetic effect, less pain, as well as better rehabilitation and quicker return to normal life [1,8,11,12].

Cardiologists performing coronaroplasty procedure offer less invasive and painless methods of myocardial revascularization. Other advantages are lower costs of these revascularization procedures and of further pharmacological treatment [11]. Cardiologists and cardiac surgeons dissatisfied with long-term results of coronaroplasty have begun to calculate which method of treatment would be the best option for myocardial revascularization. The rate of 1-year restenosis after angioplasty is estimated at 40% and at 15–20% in cases of stent implantation [11,13–15]. In contrast, it is known that implantation of LITA to LAD ensures 96% patency rate 10 years after operation [16]. The Coronary Artery Surgery Study (CASS) and other investigations have shown that the use of the LITA as a bypass conduit in coronary surgery improves the survival rates in the long-term follow-up (10–15 years) [16–18]. There are multiple randomized comparable trials which are conducted to evaluate the efficiency of both methods.

These two methods undoubtedly bring some limitations. In the case of angioplasty, it is very risky or even impossible to be carried out in patients with multiple stenosis or with occlusion in proximal segment of LAD [11,13–15]. A limitation to less invasive procedures using ‘mini-access’ is the possibility of revascularization of only one artery [1,2,12].

The only purpose was to extend the indications and to enlarge the group of patients who can avoid conducting of traditional CABG operations using ECC. Besides, it seems that both techniques supplement each other and allow performance of complete revascularization in that group of patients with multivessel coronary disease in whom application of each of these methods separately would not be effective.

Our preliminary report is the best example of new challenges. According to classical indications, our patients should qualify for routine cardiac operation. A less invasive cardiac operation provides us with the possibility of performing safe and precise grafting using the thoracic artery. Application of videoscopic harvesting of LIMA and a stabilizer for better immobilization of the operating field improved the safety standards and precision of cardiac surgery [2,7,8,19,20].

It seems that we now face some revaluations and inventions of new concepts concerning the choice of coronary disease treatment. The approach of new surgical, less invasive methods of treatment gives us the opportunity to look for new solutions in that field. One can expect that criteria for such procedures will become less strict. We know that so-called off-pump operations are particularly beneficial in patients with severely impaired left ventricle, elderly people with disseminated atherosclerosis of the aorta and other arteries, and in patients with severe comorbidities.

A steady advance in interventional cardiology (e.g. new technology of stent production: ELUT coronary stent) aiming for improvement of long-term results of coronoplasty and stenting, comes to one conclusion: cardiologists as well as cardiac surgeons should combine their desires to improve the safety and comfort standards of their patients.

The hybrid procedures are safe and effective methods for complete revascularization in selected patients with double-vessel coronary artery disease (patients with type C lesion in the proximal LAD). This method allows performance of complete revascularization with minimization of surgical trauma. So far, long-term results of HMR are limited by the results of PCI.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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  9. FitzGibbon G., Kafka H., Leach A., Keon W.J., Hooper G.D., Burton J.R. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5065 grafts related to survival and reoperation in 1388 patients during 25 years. J Am Coll Cardiol 1996;28:616-626.[Abstract]
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