Left Internal Mammary Artery to Left Anterior Descending Artery. An Alternative for old, High-Risk, Multivessel, Coronary Artery Disease Patients and an Approach for Hybrid Revascularization

Federico Benetti,Natalia Scialacomo,Jessica Gonzalez

doi:10.31579/2641-0419/230

Abstract

In 1997, the first ambulatory off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was performed via xiphoid approach, an intervention known today as the MINI-OPCAB operation. This operation has been performed in more than 150 patients around the world for the management of single and multiple vessel coronary artery disease, and 70 of those cases underwent the procedure in our Foundation from 1997 to 2021, showing no operative mortality or reintervention rates, low conversion rates, early hospital discharge, and 100% graft patency at the follow-ups. The minimally invasive direct coronary artery bypass (MIDCAB) procedure was introduced in 1994 by Benetti from Argentina, and was developed based on our previous experience performing off-pump coronary surgery by manipulating the ascending aorta through a left-sided small thoracotomy. Although it represents one of the most common minimally invasive procedures done worldwide, the original technique is not easy to reproduce, and in most cases the pleura is opened, which increases patients pain, morbidity, hospital length of stay, and hinders the realization of immediate hybrid revascularization after the procedure. The latest minimally invasive approaches for CABG include robotic-assisted procedures, in which the IMAs are harvested using robotic technology or the whole procedure is done using robotic technology. This approach has shown adequate short-term clinical results, however, there are no studies available reporting the procedure’s long-term results. Conclusion: The MINI-OPCAB operation is a friendly approach to perform Minimally Invasive Coronary Bypass Surgery in old, high-risk, multivessel coronary artery disease patients, and it represents a good intervention alternative for the majority of cardiac surgeons and cardiac specialized centers. We also consider this approach as ideal for patients who further require Hybrid Revascularization; however, more experience is needed to validate this initials results.

Highlights

Pulmonary artery towards the apex of the heart to visualize the left anterior descending artery (LAD) and define the potential site of anastomosis, the patient is heparinized, the LAD is occluded with 5-0 Prolene, a mechanical stabilizer is positioned in the beating heart to permit a steady incision and stitching, and the left internal mammary artery (LIMA)-LAD anastomosis is performed. [1,4] After ensuring an adequate blood flow, pulsatility and resistance index on the graft with the MediStim System, the mammary artery is fixed with two 7-0 Prolene stitches in both sides at 1 cm from the anastomosis, drains are placed avoiding contact with the graft, and the sternum is closed using one or two wires. [1,4]
There was no operative mortality reported, 1 (4%) patient required conversion to midline sternotomy, the reintervention rate was 0%, 55 (79%) patients were extubated in the operating room, and the mean length of hospital stay was 60 hours
Some of the benefits of this technique are that: it is simpler than the traditional CABG; it allows converting the operation, if necessary, by extending the sternotomy incision; an adequate mammary harvesting, skeletonization and blood flow and resistance measurement can be done to ensure the quality of the anastomosis; there is lower risk as the aorta is not manipulated; and preserving the upper sternum allows for future interventions on the aortic valve

Summary

Introduction

In 1997, the first ambulatory off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was performed via xiphoid approach (xiphoid lower sternotomy incision) using three-dimensional video technology in a patient with a long xiphoid appendix. [1,2,3,4] In the Mini Off-Pump Coronary Artery Bypass Surgery (MINI-OPCAB) an incision is made over the sternum to the level of the third or fourth intercostal space (according to the patient anatomy), a retractor is placed to ensure proper visualization of the left mammary artery, and around 8cms of the left mammary artery are dissected, skeletonized and clamped making sure the angle where the artery is still attached to the sternum is below 20 degrees to avoid potential kinking. [1,4] the pericardium is opened from the left border of the Auctores Publishing LLC – Volume 5(1)-230 www.auctoresonline.org ISSN: 2641-0419J. In 1997, the first ambulatory off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was performed via xiphoid approach (xiphoid lower sternotomy incision) using three-dimensional video technology in a patient with a long xiphoid appendix. Pulmonary artery towards the apex of the heart to visualize the LAD and define the potential site of anastomosis, the patient is heparinized, the LAD is occluded with 5-0 Prolene, a mechanical stabilizer is positioned in the beating heart to permit a steady incision and stitching, and the LIMA-LAD anastomosis is performed. [1,4] After ensuring an adequate blood flow, pulsatility and resistance index on the graft with the MediStim System, the mammary artery is fixed with two 7-0 Prolene stitches in both sides at 1 cm from the anastomosis, drains are placed avoiding contact with the graft, and the sternum is closed using one or two wires. Pulmonary artery towards the apex of the heart to visualize the LAD and define the potential site of anastomosis, the patient is heparinized, the LAD is occluded with 5-0 Prolene, a mechanical stabilizer is positioned in the beating heart to permit a steady incision and stitching, and the LIMA-LAD anastomosis is performed. [1,4] After ensuring an adequate blood flow, pulsatility and resistance index on the graft with the MediStim System, the mammary artery is fixed with two 7-0 Prolene stitches in both sides at 1 cm from the anastomosis, drains are placed avoiding contact with the graft, and the sternum is closed using one or two wires. [1,4]

Methods

Results

Conclusion