左胸小切口搭桥mmcts.2004.000778[1]

1� 2005 European Association for Cardio-thoracic Surgery doi:10.1510/mmcts.2004.000778 Left anterior small thoracotomy procedure Gabriele Di Giammarco*, Marco Pano, Marco Contini, Piero Pelini, Alessandro Di Francesco, Marco Valente, Michele Di Mauro Division of Cardiac Surgery, University ‘‘G. D’Annunzio’’, S. Camillo de Lellis Hospital, via Forlanini 50, 66100 Chieti, Italy The left anterior descending (LAD) artery off-pump grafting with the left internal mammary artery (LIMA), via a left anterior small thoracotomy (LAST operation) introduced, for the first time, by Vasilii Kolesov in 1964, gained popularity in the second half of the 1990s. Patients with single LAD disease (not suitable for interventional treatment) or patients showing multi- vessel disease with the other coronaries occluded and refilled by collateral circulation, but not graftable because of technical issues, can be considered candidates for this type of operation. The incision is performed at the 4th intercostal space. Pectoralis and intercostal muscles are dissected and the pericardium is opened. The LIMA is harvested as a pedicle up to the clavicle to reach a more distal and/or more lateral anastomotical site. After the stabilizer has been positioned, the LAD is incised and an intracoronary shunt is inserted. The anastomosis is then performed on a beating heart. Finally, the anastomosis is checked by means of a transit-time flowmeter. The intercostal space is then closed in a standard fashion, leaving a drainage inside. In our experience, 853 patients underwent the LAST operation. Early mortality rate was 1.2% with a nine-year survival of 91.3"1.0. Keywords: Left anterior descending (LAD); Left anterior small thoracotomy (LAST); Left internal mammary artery (LIMA) Introduction History Off-pump left anterior descending (LAD) grafting using left internal mammary artery (LIMA), via a standard left anterior thoracotomy, was introduced for the first time in 1964 by Vasilii Kolesov w1x. It has been an isolated experience until the 1990s, when a group of surgeons called Benetti, Acuff, Rob- inson, Subramanian and Calafiore w2–6x reproposed the same procedure with only a few modifications. The most important being a minimal invasive access * Corresponding author: Tel.:q39-087-135 8628; fax:q39-087-135 7552. E-mail: gabriele.digiammarco1@tin.it (left anterior small thoracotomy, LAST operation). The possibility to revascularize the most important coro- nary artery, using the most important arterial conduit w7x, generated a great deal of interest, even if some concerns about technical aspects and midterm results have been overcome only in the second half of the 1990s, with the advent of different stabilization systems w8x and the publication of fairly good midterm results w9x. Surgical indications Candidates for the LAST operation are patients with the following characteristics: Patient with single LAD disease 1. Percutaneous transluminal coronary angioplasty (PTCA) not feasible because of technical aspects. 2 G. Di Giammarco et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000778 Video 1. Skin incision at the 4th intercostal space and pectoralis muscle flap preparation. Video 2. Pleural space opening, taking care not to damage the vas- cular pedicle. Video 3. The left descending artery (LAD) is detected on the guide of the finger. Once the epicardial course of the artery is confirmed, the pedicle isolation starts with the aid of an 8.5 inch Teflon coated cautery tip. 2. Restenosis after a STENT-PTCA procedure. 3. Surgical procedure chosen by the cardiologist or the patient himself. Patients with multiple-vessel disease Assuming that the LAD lesion is suitable for surgery, the other coronary vessels should be: 1. Occluded and refilled by collateral circulation. 2. Related to previously infarcted areas. 3. Not graftable because of technical aspects (i.e. dis- tal stenoses with small coronary size, heavy calcifications). 4. Suitable for a hybrid approach w10x. Anatomical contraindications The site for anastomosis usually falls below the sec- ond diagonal branch; therefore our attention has to be addressed to this portion of the LAD. An intramyo- cardial, calcified, small-sized (-1.5 mm) LAD should be avoided, if these anatomical aspects can be rec- ognized at the angiography. An intramyocardial LAD could be suspected looking at the coronary course in a lateral view of the angiography: a straight coronary segment between two downward curvatures could be sufficient to guess this anatomical situation. Some- times the heart is rotated to the right; in this situation the position of the LAD becomes substernal and the anastomosis is exposed to a possible technical fail- ure. These cases are not good candidates for the pro- cedure and should be sorted out with a proper preoperative screening. Anesthetical management Anesthesia is managed according to the experience of the team. The only targets that should be consid- ered are the short duration of the procedure and the need to control postoperative pain, both issues improve the chances of discharging the patient very early in the postoperative course w11x. Surgical technique The patient is positioned on the operating table in the supine position as usual. No pillar is required as the patient is set up on his back in the usual fashion. The operation begins with the skin incision at the 4th inter- costal space or, in case of a female patient, on the submammalian groove. The pectoralis muscle edge is divided from the fifth rib, so disclosing the fourth inter- costal space (Video 1). The pleural space is then opened from the lateral towards the medial direction, taking care not to damage the internal mammary artery pedicle, usually running 1–2 cm away from the left sternal border (Video 2). The pericardium is then incised over the LAD on the guide of the finger, that is usually slit over the heart surface, from the right to left ventricle. The LAD course is usually located in the area where the increase in stiffness is felt. Once the epicardial course of the artery is confirmed, the ped- icle isolation then starts with the aid of an 8.5 inch Teflon coated cautery tip (Video 3). Before the pro- cedure is started, the left lung is taken away using wet swabs. In order to accomplish the harvesting a proper retractor (ACCESS MPTM Lift – MMCTSLink 54) is used to raise the upper chest, making the mammary course more visible (Video 4). Videoscopy is not required as harvesting is possible under direct vision 3 G. Di Giammarco et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000778 Video 4. LIMA harvesting starts by using a special retractor. Video 5. Frontal view: harvesting the left internal mammary artery up to the clavicle allows a more lateral target anastomotical site to be reached. Video 6. Sagittal view: harvesting the left internal mammary artery up to the clavicle allows a more distal target anastomotical site to be reached. Video 7. LIMA harvesting (1st step): a deep cautery incision is per- formed approximately 1 cm laterally to the artery, from the first rib to the chest opening. Video 8. LIMA harvesting (2nd step). Video 9. LIMA harvesting (3rd step): in this particular patient the videoscopy gave us the chance to demonstrate what is described by de Jesus et al. w12x. Video 10. LIMA harvesting (4th step). (we decided to use a videoscopic system just for bet- ter demonstrating either the pedicle isolation or the anastomotic technique). In order to take into account the anatomical variability of the LAD position or to cope with a distal anastomotical site, two different plains of dissection have to be considered. The frontal one is important with respect to a chance of reaching a more lateral LAD (Video 5). The sagittal plain allows the chance to reach a more distal site (Video 6). The first step of the IMA isolation is a deep cautery inci- sion, running about 1 cm laterally to the artery from the first rib to the chest opening (Video 7). Starting from the chest opening, the pedicle is progressively isolated from lateral to medial and from caudal to cra- nial direction, cutting every arterial or venous branch between two hemoclips (Videos 8–10). After mobili- zation of the IMA, collateral blood flow could reach the sternum by way of a sternal/intercostal (S/I) IMA 4 G. Di Giammarco et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000778 Video 11. The more proximal IMA isolation guarantees that the graft is not jeopardized by the lung excursion. Video 12. An epicardial adipose tissue flap is prepared. Video 13. The satellite veins are both ligated and the tip of the mammary artery is skeletonized. Video 14. After having cut pleural remnants along the medial aspect of the pedicle a solution of papaverine in saline is injected into the mammary artery and it is then allowed to dilate after the distal end is ligated with a hemoclip. Video 15. The left internal mammary artery tip is prepared, the clamp is opened and the intra-artery flow is checked. A 5/0 prolene is then passed around the LAD proximally to the chosen anasto- motical site. Video 16. The stabilizer is positioned and the artery is incised after proximal snaring. A soft intracoronary shunt is positioned and the artery unclamped. A couple of additional stay-sutures are passed through the epicardium. branch. For this to occur, the point of division of the S/I branch into its sternal and intercostal sub-branch- es must be protected, clipping distally the common trunk of the collateral branch (Video 9) w12x. The iso- lation so carried out guarantees that the graft is not jeopardized by the lung excursion. In fact a very prox- imal IMA isolation beyond the chest curvature towards the clavicle produces a pedicle lying on the medias- tinal pleura below the anterior margin of the lung (Vid- eo 11). The following step is the epicardial adipose tissue flap preparation (Video 12) which is very useful to protect from above either the pedicle or the anas- tomosis, so avoiding development of direct adhesions with the chest wall. A possible further operation done by median sternotomy will find the pedicle almost free to be gently dissected. The satellite veins are both ligated and the tip of the mammary artery skeletoni- zed (Video 13). After cutting the pleural remnants along the medial aspect of the pedicle according to the distance towards the anastomotical site, a solu- tion 1:10 of papaverine in saline is injected into the mammary artery via a 20G olive-tipped needle. The mammary is then allowed to dilate after the distal end is ligated with a hemoclip (Video 14). A 5/0 prolene is then passed around the LAD proximally to the chosen anastomotical site. The stabilizer (ACCESS MVTM – MMCTSLink 54) is positioned and the artery is incised after proximal snaring (Video 15). A soft intracoronary shunt (MMCTSLink 55) is then positioned and the artery unclamped. The arteriotomy is then adjusted in length. A couple of additional stay-sutures are passed through the epicardium on both sides of the anasto- motical site to better stabilize the area (Video 16). 5 G. Di Giammarco et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000778 Video 17. The arteriotomy is then adjusted in length. The anasto- mosis is started from the heel. Video 18. The left internal mammary artery is approximated to the coronary artery. The anastomosis is then completed. Video 19. The flow through the anastomosis is checked by a transit time flowmeter. The pedicle is covered with the adipose tissue flap. The thoracotomy is closed leaving inside a chest drainage. Graph 1. Survival 9 years after the operation. Graph 2. Event-free survival 9 years after the operation. After the LIMA tip has been prepared the anastomosis is started (Video 17). The LIMA is approximated to the LAD after the first stitches on the heel. The anasto- mosis is then completed and the suture is tied on the left side of the contour (Video 18). The functioning of the anastomosis is checked by means of a transit time flowmeter (MMCTSLink 56). The pedicle is covered with the adipose tissue flap previously created in order to protect it from strong adhesion to the chest wall. The thoracotomy is closed in a standard fashion leaving a chest drainage inside (Video 19). Results In our Institution, from November 1994 up to Decem- ber 2002, 853 LAST operations have been performed. Mean age was 61.5"10.1 years. Patients with single vessel disease were 384 whereas 469 patients had multivessel disease. In the first group mean Euro- SCORE was 3.0% (median 1.7%) vs. 4.0% (median 2.3%) in the second group, Ps0.003. ● Thirty-day mortality and morbidity were 1.2% and 2.0%, respectively. ● Nine-year survival and event-free survival were 91.3"1.0 and 82.8"1.4, respectively (Graphs 1 and 2). 6 G. Di Giammarco et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000778 Video 20. The postoperative angiography shows the patency of the LIMA on the LAD. ● More than 9 years after the operation, the overall reintervention rate was 8.1%, whereas in the graft- ed area it was 3.2%. ● Early (F1 month) angiographic patency rate and perfect patency rate w13x were 96.8% and 95.0%, respectively (Video 20). ● Late ()1 month) angiographic patency rate and perfect patency rate were 86.1% and 83.6%, respectively. References w1x Kolessov VI. Mammary artery–coronary artery anastomosis as method of treatment for angina pectoris. 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