Determinants of successful endoscopic internal thoracic artery harvesting: a prospective analysis.

Abstract

Endoscopic internal thoracic artery (ITA) harvesting is employed during minimal-access coronary artery bypass grafting. To improve case selection, we prospectively analyzed our entire experience to identify variables that predict intraoperative conversion to sternotomy. We performed a prospective study from September 1999 to November 2003 of 100 consecutive patients with an endoscopically harvested left ITA (LITA). Success was defined as an endoscopic dissection of the LITA sufficient to reach the anastomosis. Multivariate logistic regression analysis was performed to identify independent preoperative and procedural predictors of success. The measured parameters (mean +/- SD) were age (62 +/- 9 years), height (174 +/- 9 cm), weight (81 +/- 14 kg), and logistic Euroscore (2.0 +/- 1.7). Patients comprised 8 (8%) women, 17 (17%) with urgent operations, 42 (42%) with multiple vessel disease, 17 (17%) with a left ventricular ejection fraction <50%, 2 (2%) redo procedures, and 3 (3%) with pleural disease. The Zeus robot was used in 17 patients (17%). Eight-eight (88%) of the LITA were successfully harvested endoscopically. Among the 12 patients who underwent conversions, pleural adhesions were the most common finding (n = 4, 33%). One LITA was unusable. In the final multivariate model, lung disease was a negative predictor of successful endoscopic harvest (odds ratio, 0.13; 95% confidence interval, 0.02-0.63; P =.012). The variables of age, sex, left ventricular function, logistic Euroscore, operative priority, and use of the Zeus robot did not achieve statistical significance. Acceptable conversion rates and low conduit wastage are achievable during a unit's initial experience. Lung disease is associated with increased conversion frequency, and surgeons embarking on endoscopic harvesting should consider excluding these patients to improve their chances of success. Pleural adhesions increase the technical difficulty of surgery.