Invasive Bypass Grafting Research Articles

Unilateral left-sided thoracoscopic ablation of atrial fibrillation concomitant to minimally invasive bypass grafting of the left anterior descending artery.

OBJECTIVESThoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery.METHODSRetrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021.RESULTSTwenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n = 23) and right (n = 22) pulmonary veins and box (n = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n = 1; pleural- and pericardial effusion n = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P = 0.01].CONCLUSIONSIn this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis.

Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: Early outcome and short-mid-term follow up results

To explore the feasibility, safety and mid-term outcome of minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) surgery. Data of patients who underwent MICS CABG between November 2015 and November 2017 in Peking University Third Hospital were retrospectively analyzed. Results were compared with the patients who underwent off-pump coronary aortic bypass grafting (OPCABG) surgery over the same period. The two groups were matched in propensity score matching method according to age, gender, left ventricular ejection fraction, body mass index, severity of coronary artery disease, smoking, diabetes mellitus, hypertension, hyperlipidemia, renal insufficiency, history of cerebrovascular accident, and history of chronic obstructive pulmonary disease (COPD). There were 85 patients in MICS CABG group, including 68 males (80.0%) and 17 females (20%), with an average age of (63.8±8.7) years; 451 patients were enrolled in OPCABG group, and 85 patients were matched by propensity score as control group (OPCABG group). There was no significant difference in general clinical characteristics (P>0.05). The average grafts of MICS CABG and OPCABG were 2.35±0.83 and 2.48±0.72 respectively (P=0.284). No conversion to thoracotomy in MICS CABG group or cardiopulmonary bypass in neither group occurred. There was no significant difference in the major adverse cardiovascular events (MACCEs, 1.17% vs. 3.52%), reoperation (2.34 vs. 3.52%), new-onset atrial fibrillation rate (4.70% vs. 3.52%) or new-onset renal insufficiency rate (1.17% vs. 0%) between MICS CABG group and OPCABG group (P>0.05). The operation time in MICS CABG group was longer than that in OPCABG group [(282.8±55.8) min vs. (246.8±56.9) min, P < 0.05], while the time of ventilator supporting(16.9 h vs. 29.6 h), hospitalization in ICU [(29.3±20.8) h vs. (51.5±48.3) h] and total hospitalization [(18.3±3.2) d vs. (25.7±4.2) d] in MICS CABG group were shorter than those in OPCABG group (P < 0.05). The total patency rate (A+B levels) of MICS CABG was 96.5% after surgery. There was no significant difference in MACCEs rate between the two groups [1.18%(1/85) vs. 3.61%(3/83), P>0.05] in 1-year follow up. The MICS CABG surgery is a safe and feasible procedure with good clinical results in early and mid-term follow-up.

Пластика аневризми лівого шлуночка при малоінвазивному багато- судинному коронарному шунтуванні

Пластика аневризми лівого шлуночка при малоінвазивному багато- судинному коронарному шунтуванні

Efficacy of oxycodone combined with thoracic paravertebral block for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting

Objective To evaluate the efficacy of oxycodone combined with thoracic paravertebral block (TPVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCABG). Methods Thirty-two American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes, aged 60-75 yr, weighing 50-85 kg, scheduled for elective MIDCABG under general anesthesia, were divided into 2 groups (n=16 each) using a random number table method: morphine plus TPVB group (group MT) and oxycodone plus TPVB group (group OT). Paravertebral catheter was placed at T4, 5 before induction of anesthesia to perform left thoracic paravertebral puncture, patients were tracheally intubated, and 0.375% ropivacaine 15 ml was injected followed by continuous infusion of 0.375% ropivacaine 5 ml/h until 0.5 h before the end of surgery.Both groups received patient-controlled analgesia (PCA) after surgery.The PCA solution contained 1 mg/ml morphine 60 ml in group MT or 1 mg/ml oxycodone 60 ml in group OT, and the PCA pump was set up to deliver a 1 mg bolus dose with a 10-min lockout interval and background infusion at 1 ml/h after a loading dose of 2 mg, with the maximum dose of 20 mg every 4 h. Pethidine 50 mg was intravenously injected as a rescue analgesic to maintain visual analog scale≤4.The intraoperative consumption of fentanyl, consumption of analgesics for PCA within 48 h after surgery, ratio of total to effective pressing times of PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia, score of satisfactory analgesia, extubation time, duration of intensive care unit stay and length of hospital stay were recorded.The development of nausea and vomiting, pruritus, respiratory depression, atelectasis and somnolence was recorded within 72 h after surgery. Results Compared with group MT, the intraoperative consumption of fentanyl, consumption of analgesics for PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia and ratio of total to effective pressing times of PCA were significantly decreased, the score of satisfactory analgesia was increased, the extubation time and duration of intensive care unit stay were shortened, and the incidence of nausea and vomiting, pruritus, respiratory depression and somnolence was decreased in group OT (P<0.05). Conclusion Oxycodone combined with TPVB provides safe and effective efficacy for postoperative analgesia in patients undergoing MIDCABG. Key words: Oxycodone; Analgesia, patient-controlled; Nerve block; Coronary artery bypass, off-pump

Minimally invasive direct coronary bypass surgery via distal mini-sternotomy

Minimally invasive direct coronary artery bypass grafting (MIDCAB) was developed to decrease perioperative morbidity, some of which may be related to the use of cardiopulmonary bypass and to cross-clamping of the aorta. We report our initial experience with multivessel MIDCAB via distal mini-sternotomy (DIMS). DIMS is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery (LAD), diagonal branches, and right coronary artery (RCA). Between January 2016 and January 2017, 12patients with significant coronary artery disease of the LAD and the RCA underwent multivessel, all-arterial MIDCAB through adistal midline skin incision from the fourth intercostal space to the xyphoid process, with L‑ or T‑shaped division of the sternum. The mean age of the patients was 61.5 ± 5.2years (range: 52-71years). We performed all-arterial revascularization using the left internal mammary artery in 12patients, the radial artery in ten, and the right internal mammary artery in twopatients. The mean number of grafts per patient was 2.08 ± 0.4 (range: 2-3). The mean length of the skin incision was 8.5 ± 1.3 cm (range: 7-11 cm). There was no perioperative ischemia, postoperative bleeding, or arrhythmia events. No postoperative cognitive dysfunction occurred. The mean hospital stay was 5.6days. No major adverse cardiac events (MACE) occurred at the 12-month follow-up. At follow-up, all patients were in New York Heart Association classI and there were no wound complications. Although MIDCAB-DIMS is technically more demanding than conventional procedures and our experience is limited, we conclude that this technique can be used safely in selected patients, with promising 12-month follow-up results.

Pain and the Quality of Life Following Robotic Assisted Minimally Invasive Surgery.

Minimally invasive bypass grafting is a promising surgical treatment in proximal LAD stenosis procedures. The main goal of this study was to make comparisons between robotically assisted minimally invasive coronary bypass surgery and conventional surgery in isolated proximal LAD lesions in terms of pain and quality of life improvement. The study contains patients with proximal LAD lesions who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery between June 2005 and November 2012. Fifty patients treated with coronary bypass with cardiopulmonary bypass and complete sternotomy were categorized as Group 1. Fifty patients who applied for robotically assisted minimally invasive bypass surgery were categorized as Group 2. The evaluations of pain and quality of life were done according to the Verbal Rating Scale (VRS) and SF-36 health survey questionnaire, respectively. The conventional bypass group and robotic group had 4.8 ± 1.9 years and 4.3 ± 1.6 years mean follow-up time, respectively. The robotic bypass group had a significantly shorter ICU stay and hospital stay than the conventional bypass group (P &lt; .05). The pain score was higher in the robotic bypass group on the 1st postoperative day (P &lt; .05), but the score on the 4th postoperative day was higher in the conventional bypass group (P &lt; .05). In terms of domains of the SF-36 questionnaire, patient scores were significantly higher in patients who were operated with robotically assisted minimally invasive direct coronary artery bypass (MIDCAB) procedure than in patients who were operated with conventional bypass technique. Patients operated with robotically assisted MIDCAB procedure had results with lesser pain, shorter ICU stay, and shorter hospital stay than the other group in isolated proximal LAD stenosis. The same group also had better quality of life results according to the SF-36 questionnaire results.

Is chronic total coronary occlusion a risk factor for long term outcome after minimally invasive bypass grafting of the left anterior descending artery?

Introduction: Chronic total occlusion (CTO) of coronary vessels is still a challenge for PCI and data show unfavorable long term results compared to medical therapy. The influence of CTO for long term outcome after minimally invasive bypass grafting is to be evalueted.

Is Chronic Total Coronary Occlusion a Risk Factor for Long-Term Outcome After Minimally Invasive Bypass Grafting of the Left Anterior Descending Artery?

Chronic total occlusion (CTO) of coronary vessels is still a challenge for percutaneous coronary intervention and recent data show unfavorable long-term results compared with medical therapy. It is unclear whether CTO is also a negative predictor for long-term outcome in minimally invasive bypass grafting. From 1996 to 2007 minimally invasive surgical revascularization of the left internal mammary artery to the left anterior descending artery (LAD) was performed in 1,800 patients. Demographic data, risk factors, perioperative outcome, and annual follow-up were obtained from all patients. Estimated survival and freedom from major adverse cardiac and cerebrovascular events or recurrence of angina with log-rank tests and Cox regression analysis for identification of independent risk factors were calculated for patients with (420 patients) and without (1,380 patients) CTO of the LAD. Revascularization of the LAD could be completed in all but one patient (99.8% success rate with CTO). At 5 years estimated overall survival was 90.5% (95% confidence interval [CI] 85.8 to 95.5) with CTO and 90.4% (95% CI 85.8 to 95.1) without CTO (p = 0.91). Freedom from major adverse cardiac and cerebrovascular events and angina with or without CTO at 5 years was 83.2% (95% CI 77.6 to 88.8) and 85.5% (95% CI 82.6 to 88.1), respectively (p = 0.64). Chronic occlusion of the target vessel and other preoperative factors were not identified as risk factors for major adverse cardiac and cerebrovascular events during follow-up. As opposed to percutaneous coronary intervention, minimally invasive bypass grafting of a totally occluded LAD is almost always possible and chronic occlusion is not a negative predictor for short and long-term outcome. Minimally invasive bypass grafting of the LAD should be considered the treatment of choice for chronically occluded left anterior descending arteries.

Chronic total coronary occlusion is no risk factor for long term outcome after minimally invasive bypass grafting of the left anterior descending artery

Chronic total coronary occlusion is no risk factor for long term outcome after minimally invasive bypass grafting of the left anterior descending artery

A hybrid alternative for high risk left main disease

Percutaneous revascularization strategies for bifurcation disease of the left main are complex and carry significant risk. These risks are magnified in the setting of a left main which trifurcates. In a patient with complex ostial disease of two of the three limbs of a left main trifurcation, turned down for conventional bypass surgery, we report on a hybrid approach for complete revascularization, consisting of minimally invasive bypass grafting of the LAD combined with simultaneous drug eluting stent placement.

Robot Assisted Left Internal Thoracic Artery Harvesting in Minimally Invasive Direct Coronary Artery Bypass: Report of a Case

Coronary artery bypass grafting (CABG) is usually performed through a sternotomy. Minimally invasive direct coronary artery bypass grafting (MIDCABG) has been used recently in a select group of patients with severe lesions of the left anterior descending (LAD) coronary artery. CABG has been proven difficult to adapt to a totally endoscopic approach because of the inability to perform a precision microvascular-sutured coronary anastomosis with conventional endoscopic instrumentation. The Da Vinci telemanipulation system has six degrees of freedom and allows free orientation in space and a remote, tremor-free, three-dimensional visual image. We report hereby a 76-year-old male who suffered from substernal chest pain that radiated to the left shoulder for one day. Coronary angiography confirmed coronary artery disease with 90% occlusion of the LAD coronary artery. The patient volunteered to receive the operation. Robotically assisted left internal thoracic artery (LITA) harvesting and direct off-pump anastomosis to the LAD through small thoracotomy incisions were performed safely. The patient improved clinically and was free of angina at the six-month follow-up. We describe an alternative procedure for one-vessel disease using robotic takedown of the LITA and off-pump anastomosis to the LAD artery through small incisions. This procedure is associated with minimal blood loss and ventilatory requirements, and short stays in the intensive care unit and hospital.

Impact of multivessel coronary artery disease on outcome after isolated minimally invasive bypass grafting of the left anterior descending artery

Background The outcome in patients treated surgically for coronary artery disease is known to be influenced by the extent of the disease. Whether this factor also has an effect in patients undergoing isolated minimally invasive revascularization of the left anterior descending (LAD) artery using the internal thoracic artery (ITA) (MIDCAB) has not been looked at. Thus, this study sought to evaluate the impact of multivessel disease (MVD) on midterm outcome after MIDCAB. Methods From 1996 to 1999, 411 patients received a MIDCAB at our institution and were now followed up. Isolated disease of the LAD (SVD –single vessel disease) was presented in 262 patients (63.7%) and 149 patients (36.3%) had MVD at the time of operation. The reasons for apparent incomplete revascularization in patients with MVD were very small target vessels (< 1.0-mm diameter), stenoses of less than 50%, distal localization of the stenoses, long-term patency after angioplasty, or an extensive risk for sternotomy and(or) cardiopulmonary bypass. The midterm outcome was evaluated by questionnaires sent to the patients and their physicians. Results The mean follow-up was 29.4 ± 11.1 months. The incidence of myocardial infarction was significantly higher in MVD as compared to SVD patients (8.1% vs 1.9%, p = 0.04). Patients with MVD had significantly more subsequent percutaneous transluminal coronary angioplasty (10.7% vs 5.3%, p = 0.049) and a similar number of repeat surgical revascularizations as compared to SVD patients. Patients with MVD had a significantly higher total 3-year mortality as compared to SVD patients by Kaplan-Meier estimate (8.7% vs 3.1%, relative risk [RR] = 2.56, p = 0.011). The 3-year cardiac mortality was significantly higher in patients with MVD as compared to SVD (4.0% vs 0.4%, RR = 9.48, p = 0.0054). After adjustment of baseline characteristics by Cox regression analysis, the 3-year risk of cardiac death was significantly higher in the MVD groups (RR = 2.2, confidence interval [CI] 95%: 1.8 to 4.65, p = 0.029). Conclusions Patients with isolated disease of the LAD appear to benefit from ITA grafting in the form of a MIDCAB procedure. Here, it should be an approach of choice. The results show that MVD is an independent risk factor for outcome in patients undergoing a MIDCAB procedure. Nevertheless, the midterm morbidity and mortality in MVD patients after a MIDCAB procedure where the LAD is the only target vessel for interventional or surgical treatment is acceptable despite a higher morbidity than in SVD patients.

Impact of diabetes on outcome following isolated minimally invasive bypass grafting of the left anterior descending artery

BackgroundThe outcome in patients treated by conventional coronary artery bypass grafting (CABG) for coronary artery disease is negatively influenced by the presence of diabetes. The relative effect of diabetes in patients undergoing isolated minimally invasive revascularization of the left anterior descending artery (LAD) using the internal thoracic artery (ITA) has as yet not specifically been looked at. Thus, this study sought to evaluate the impact of diabetes on mid-term outcome following minimally invasive coronary artery bypass grafting (MIDCAB). MethodsFrom 1996 to 1999, 411 patients received a MIDCAB procedure at our institution and were now followed up. In this study population there were 63 diabetic patients (15.3%) and 348 nondiabetic patients (84.7%). Isolated proximal stenoses or an occlusion of the LAD were present in 262 patients (63.7%), whereas 149 (36.3%) had multi-vessel disease (MVD) at the time of the MIDCAB procedure. The clinical outcome was evaluated by questionnaires sent to the patients and their physicians. ResultsThe mean follow-up was 29.4 ± 11.1 months. The incidence of myocardial infarction was significantly higher in diabetics as compared to nondiabetics (9.5% vs 3.2%, p = 0.034). Diabetics and nondiabetics had similar rates of subsequent revascularization procedures during follow-up. Cumulative total survival of diabetic and nondiabetic patients was not statistically different. The 3-year cardiac mortality was however significantly higher in diabetic than in nondiabetic patients if MVD was initially present (Kaplan-Meier estimate: 10.7% vs 2.5%, relative risk [RR] = 5.5, p = 0.017 by log-rank test). The 3-year cardiac mortality in diabetic and nondiabetic patients with isolated disease of the LAD (single vessel disease [SVD]) was not significantly different. After adjustment of baseline characteristics by Cox regression analysis the 3-year risk of cardiac death was significantly higher in the diabetic group (RR = 1.82, CI 95%:1.2 to 3.3, p = 0.045). ConclusionsThe results support diabetes to be an independent risk factor for outcome in patients with MVD undergoing a MIDCAB procedure in analogy to those undergoing CABG procedures. Diabetics with isolated disease of the LAD, however, benefit out of proportion from this treatment modality.

Left thoracotomy approach in reoperative off-pump coronary revascularization: bypass grafting from the left axillary artery or descending thoracic aorta.

Reoperative coronary bypass grafting is at high risk. Particularly in redo cases where the patent graft is running near the midline of the sternum, the graft may be exposed to injury by a median sternotomy and subsequent dissection. Whereas, off-pump bypass grafting from the left axillary artery or descending thoracic artery by a left thoracotomy approach is safe for preventing graft damage. From March 1998 to February 2002, we performed off-pump coronary artery bypass grafting by a left thoracotomy approach in 9 patients. The left axillary artery was used as the inflow vessel in 4 cases, and the descending thoracic aorta in 5. The radial artery was anastomosed proximally to the axillary artery in 4 cases and the descending thoracic aorta in one case. The saphenous vein graft was anastomosed proximally to the descending thoracic aorta in 4 cases. Transdiaphragmatic minimally invasive bypass grafting for the right coronary artery was simultaneously performed in 3 cases. Postoperative cardiac events were ventricular arrhythmia in 6 cases and supraventricular arrhythmia in 3 cases. There was no damage to the patent grafts. Postoperative coronary angiography performed in 8 cases revealed all the grafts to be patent without stenosis. Cardiac symptoms were not found after the operation in any of the cases. These procedures can prevent the injury to patent grafts caused by a median sternotomy, and will be one of the useful strategies for reoperative off-pump coronary artery bypass grafting.

Novel proximal and distal anastomotic devices for coronary artery bypass surgery

THE CURRENT LITERATURE describes many varied experimental and clinical applications of minimally invasive techniques to enhance outcomes after coronary artery bypass grafting (CABG). Many techniques facilitating anastomotic procedures are described, but long-term data supporting improved patency rates, efficiency of surgical technique, and outcomes are limited. The growing need for minimally invasive procedures and means of reducing the complexity of endoscopic suturing will be the impetus that drives the development and implementation of such anastomotic devices. Applications of simultaneous suturing, stapling, clipping, stenting, and sealing devices have provided insight toward the development of clinically acceptable procedures to facilitate positive outcomes in minimally invasive CABG surgery. Proximal anastomotic devices not only decrease operative time but also allow the surgeon to avoid using a partial occlusion clamp on the ascending aorta during CABG.1 Successful reports of an aortic anastomotic device (AAD) for sutureless anastomosis to the proximal aorta of saphenous vein grafts without aortic manipulation2,3 may provide the technologic basis to pursue distal anastomotic devices in coronary surgery. However, applying such techniques to create distal anastomoses may prove more difficult and require development of unique technologies; robotic assistance toward totally endoscopic CABG makes these goals more challenging. The ideal distal anastomotic device would have applicability to all potential conduits with interchangeable proximal/distal order and a safe bailout in the case of device malfunction.4 The ability to decrease operative time, create superb anastomoses without technical imperfection, and improve long-term patency rates lends excitement to the developing frontier of distal anastomotic devices in minimally invasive CABG surgery. The objective of this review is to compare the existing devices and provide a basis for continued development of novel anastomotic devices. The anesthetic implications will be considered.

Current development of cardiac imaging with multidetector-row CT

Multidector-row CT (MDCT) with retrospective ECG gating allows scanning the entire heart with 1.25 mm slice thickness and 250 ms effective exposure time within 35 s investigation time. The resulting images allow for an accurate high-resolution assessment of morphological detail of both the coronary arteries and the cardiac chambers. Performing a contrast-enhanced MDCT angiography (MD-CTA) in addition to a non-enhanced scan for the detection and quantification of coronary calcifications may be indicated in patients with atypical chest pain and in young patients with high cardiovascular risk. This group of patients may show non-calcified plaques as the first sign of their coronary artery disease. As the proximal part of the coronary arteries is well displayed by MD-CTA it also helps to delineate the course in anomalous coronary vessels. Additional information is drawn from the preoperative use of MD-CTA do determine the distance of the left internal mammarian artery to the left anterior descending coronary artery prior to minimal invasive bypass grafting. Additional indications for MD-CTA are the non-invasive follow up after venous bypass grafting, PTCA, and coronary stent interventions. MD-CTA allows following the course of the coronary vessels to the level of third generation coronary segmental arteries. A definite diagonis to rule out coronary artery disease can be reliably made in vessels with a diameter of 1.5 mm or greater. With MDCT a number of different atherosclerotic changes can be observed in diseased coronary arteries. Non-stenotic lesions may show tiny calcifications surrounded by large areas of irregularly distributed soft tissue. Calcifications in this type of atherosclerotic coronary artery wall changes appear as ‘the tip of iceberg’. Heavy calcifications usually tend to be non-stenotic because of vessel remodelling resulting in a widening of the coronary vessel lumen. Therefore, heavy calcifications appear to ack like an ‘internal stent’ for a coronary vessel segment. Humps of soft tissue either with or without calcifications are more likely to cause significant coronary artery disease and correlate with stenoses of >50% on selective coronary catheter. These humps consist of well-defined soft tissue in the coronary artery wall. The density of this soft tissue may vary between 30–70 HU. In cases where a coronary vessel is occluded by thrombotic material, a typical sign is found with enlargement of the coronary vessel, a hypodense center and a hyperdense rim. Vessel occlusion without thrombus may also appear within a collapsed and dense lumen. In addition to the investigation of the coronary arteries, CTA with MDCT is well suited to assess the presence and morphology of myocardial scars and aneurysms, intracardial tumors and thrombi.

Enabling sutureless vascular bypass grafting with the exovascular sleeve anastomosis

Purpose: We describe a technique for end-to-end sleeve anastomosis that may enable minimally invasive bypass grafting and characterize the tensile strength, stenosis rate, durability, and healing of the anastomosis. Method: An anastomotic device assembly consisting of a cable tie–type band with mobile teeth elements is mounted on the outer surface of a polytetrafluoroethylene graft. The graft is drawn over the artery resulting in a sleeve of vessel within the graft. As the band is tightened over an intraluminal obturator, the independently mobile anchoring teeth are driven through the graft into the artery. The tensile strength of the anastomosis was compared with sutured anastomosis during in vitro studies using cadaveric human femoral arteries. For in vivo studies on pigs and goats, we used a proximal exovascular sleeve anastomosis along with a distal sutured aortic anastomosis. Survival animals were studied by angiogram postoperatively and at the time of explantation. Results: In vitro studies showed no difference in maximal tensile strength between sutured and exovascular anastomoses (10.5 ± 2.7 lb vs 10.2 ± 3.0 lb, P =.83). However, loss of continuous graft to artery interface occurred at lower loads in the sutured anastomoses (6.5 ± 0.6 lb, P <.05). In total, all 24 pigs tested in nonsurvival or survival settings sustained a successful and leakproof anastomosis. Of the 13 nonsurvival cases, maximal epinephrine-induced hypertension sustained over 15 minutes (peak systolic blood pressure > 210-250 mm Hg) was tolerated without leakage in a subgroup of five animals (100%). All 11 survival pigs had no pseudoaneurysms or stenosis relative to sutured control anastomoses at 6 week explantation (8.2 ± 1.25 mm vs 8.5 ± 1.6 mm, P =.21). The three long-term survival goats had no pseudoaneurysm or stenosis after 40 weeks. Histologic examination confirmed healing of the aorta to graft with minimal neointimal hyperplasia. Conclusion: Exovascular sutureless anastomosis appears comparable to sutured anastomosis in stenosis rate, healing, and durability, with some advantages in tensile strength and rapidity of application. (J Vasc Surg 2000;32:524-30.)

Cardiac surgery without the use of cardiopulmonary bypass: the challenges

Minimally invasive bypass grafting of the internal thoracic artery to the left anterior descending artery has become routine in many institutions. Currently, indications for single vessel revascularization are expanding to those patients not suitable to be operated upon using extracorporeal circulation, but surgeons remain rather reluctant when multivessel disease is concerned. In such cases, the 'hybrid technique', i.e. single vessel bypass grafting followed by percutaneous transluminal coronary angioplasty at a different site, seems to be a more appropriate alternative. Despite the merits of minimally invasive surgery, the majority of surgeons do not believe that it is possible to achieve the same quality of anastomosis on a beating heart as on an arrested heart.

Nursing care of patients undergoing thoracoscopic minimally invasive bypass grafting

Recent efforts in cardiac surgery to decrease cost, length of hospitalization, and morbidity without compromising care or outcomes include a method of treatment of coronary heart disease called minimally invasive coronary artery bypass grafting. This article describes the use of thoracoscopy without sternotomy, cardiopulmonary bypass, or cardioplegic arrest for grafting of the left anterior descending branch of the coronary artery with the left internal mammary artery. Preliminary information supports the concept that thoracoscopic minimally invasive bypass grafting is a less costly and less invasive procedure for patients with disease of the left anterior descending branch of the coronary artery.