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How to Perform a MIDCAB Procedure Step-by-Step in Single Vessel Disease

Tuesday, July 10, 2018

Kotowicz V, Posatini R, Fortunato G, Battellini R. How to Perform a MIDCAB Procedure Step-by-Step in Single Vessel Disease. July 2018. doi:10.25373/ctsnet.6713054.

Introduction

Since the first reports of the off-pump technique and minimally invasive access (1, 2), coronary artery bypass grafting (CABG) performed through a small anterior lateral thoracotomy without cardiopulmonary bypass has become an increasingly popular technique worldwide. The minimally invasive direct coronary artery bypass (MIDCAB) has been used for patients with a single vessel disease when a coronary stent placement failed. In this step-by-step video, the authors show their technique for this procedure.

Case Presentation

A 73-year-old female patient with severe chest pain was brought to the emergency room. The electrocardiogram (ECG) did not show ST elevation, and the cardiac enzyme levels were normal. A catheterization was performed on the coronary arteries and a 100% stenosis of the left anterior descending artery (LAD) was observed. Due to the impossibility of stent placement, a surgical solution was decided. Through a left anterior small thoracotomy, a video-assisted single bypass from the left internal mammary artery (LIMA) to LAD was performed with a good postoperative outcome.

Operative Technique

  1. A small anterior thoracotomy was performed in the left fifth intercostal space. Transesophageal echocardiography (TEE) and ECG were used to monitor ventricular function during the whole procedure.
  2. A special rib retractor (ThoraGate™, Geister®, Germany) was selected to elevate the fifth rib for improved visualization for LIMA harvesting. It is not mandatory, but in some cases a video camera can be helpful for a better harvesting technique.
  3. The artery was mobilized as high as possible, which is important to ensure an adequate length to reach the coronary artery without tension.
  4. The pericardium was opened. A silk suture can be used for traction of the pericardium.
  5. The anterior descending artery was identified.
  6. A stabilization device was positioned to expose the descending artery.
  7. A longitudinal incision was made in the coronary artery and bleeding was controlled with carbon dioxide.
  8. A 1.2 mm shunt was inserted into the coronary artery.
  9. The LIMA was prepared for bypass. Continuous stitches of 7.0 polypropylene (Prolene®, Ethicon) were used to construct an end-to-side anastomosis from the LIMA to LAD.
  10. The shunt was removed and the anastomosis was finished.
  11. The bulldog clamp was removed from the LIMA.
  12. The TEE and ECG showed no complications during the entire procedure.

Discussion

A small thoracotomy instead of the classical sternotomy could reduce notorious thorax trauma. Shorter hospital stay, less postoperative pain, and faster recovery to activities have been described by some authors who compared CABG to MIDCAB and described the latter as a feasible technique (3-5). Nonetheless, a minimally invasive thoracotomy represents a very different approach when compared to sternotomy because the operative field is external, the anatomical relationships are different, and with a small approach, the structures are difficult to observe and control. Another disadvantage is that while dissecting the mammary artery, direct vision may sometimes not be enough, so a video camera can be very useful to reach 5 to 8 cm more of this artery. A short pedicle, associated with pulmonary excursion and intimate contact with the endothoracic fascia, may cause an early bypass occlusion (6). In addition, the potential benefits of MIDCAB, the low incidence of bleeding, early mobilization, and aesthetic results may be only weak factors for promoting the adoption of this technique. The authors argue that today's development is supported by factors that are not based on evidence, such as increased demand from patients and referring physicians (7).

Conclusions

The MIDCAB technique through a left anterior small thoracotomy is an excellent choice when a single coronary vessel is affected.


References

  1. Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest. 1991;100(2):312-316.
  2. Subramanian VA, Sani G, Benetti FJ, Calafiore AM. Minimally invasive coronary bypass surgery: a multicentre report of preliminary clinical experience. Circulation. 1995;92(Suppl 1):645.
  3. Detter C, Reichenspurner H, Boehm DH, et al. Minimally invasive direct coronary artery bypass grafting (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB): two techniques for beating heart surgery. Heart Surg Forum. 2002;5(2):157-162.
  4. Greenspun HG, Adourian UA, Fonger JD, Fan JS. Minimally invasive direct coronary artery bypass (MIDCAB): surgical techniques and anesthetic considerations. J Cardiothorac Vasc Anesth. 1996;10(4):507-509.
  5. Iribarne A, Easterwood R, Chan EY, et al. The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol. 2011;7(3):333-346.
  6. Battellini R. Minimally Invasive Coronary Surgery [dissertation]. Germany: Herzzentrum Leipzig; 2001.
  7. Fortunato GA, Rios M, Battellini R, et al. Is minimally invasive mitral valve surgery possible in complex patients? Rev Argent Cardiol. 2017;85:314-319.

Comments

Very nice case and interesting video. In the video I see a sponge coming out of the wound toward the patient's left side. Was this used to help bring the LAD into the center of the wound? Also interesting that you used no silastic occluding tapes but only the shunt to control bleeding. would be interesting to hear your perspective on that.
Thank you very much Dr. T. Sloane Guy for your comment. Regarding your first question, yes we usually use a gauze to mobilize the LAD into the center of the wound in MIDCAB for a better visualization. We don´t use silastic occluding tapes except when blood is so excessive that anastomosis is not possible to perform. On the other hand, silastic occluding tapes are sometimes related to coronary injuries. In conclusion, if we can avoid using it, we´d rather working only with shunt and CO2 for bleeding control.
Congratulations for this well documented case report. Certainly limited, submammal, anterolateral thoracotomy is the method of choice - especially in young females with the described pathology to fulfill cosmetic requirements. A couple of questions: 1. Any wall motion disturbances in the respective area? 2. Any collateral flow observed by angiography? 3. Have you measured the volume of free cut end flow of the IMA? 4. If the LAD was 100 % occluded, what was the point of utilizing a intracoronary shunt? (Unless there was a substantial back flow observed.). Finally, one remark: If the proximal jaw of the retractor elevates asimmetrically the respective rib, the IMA can be easily dissected up to its origin under direct vision - especially, if the incision is made in the 4th intercostal space- which could have been feasible-as the LAD was totally occluded - at its origin.
Thank you very much, Dr. Ferenc Tarr, for your comments. There was no wall motion disturbance in the affected area, nevertheless, there is always TEE in the OR available and we use it routinely. We had measured the volume of free cut end flow of the anastomosis and it was satisfactory, it´s a normal practice when OPCABG or MIDCAB procedure is performed in our institution. Regarding the last question, yes the LAD was 100% occluded, but as you can see in the video (previous to the shunt placement), there was important backflow coming from distal LAD. I agree with your comments about that is an excellent method in selected cases, especially when a single vessel disease is presented.

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