Asian Cardiovasc Thorac Ann 2004;12:30-32
© 2004 Asia Publishing EXchange Ltd
Multivessel Total Arterial Revascularization via Left Thoracotomy
Sushil Kumar Singh, MCh,
Surya Kumar Mishra, MCh,
Deepak Kumar, MD,
Ram Deo Yadave, DM,
Subhash Kumar Sinha, MCh
Department of Cardiology & Cardio Thoracic Surgery, Batra Hospital & Medical Research Centre, New Delhi, India
For reprint information contact: Subhash K Sinha, MCh Tel: 91 11 608 6951 Fax: 91 11 6087 7661 Email: sksinha{at}del3.vsnl.net.in Department of Cardiology & Cardio Thoracic Surgery, Batra Hospital & Medical Research Centre, MB Road, New Delhi 110 062, India.
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ABSTRACT
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Off-pump coronary artery bypass grafting is now becoming the preferred method of coronary revascularization. The trend is towards complete revascularization, preferably arterial. We are describing here a method of multivessel, total arterial, complete revascularization via an anterolateral thoracotomy approach in 27 patients. There was an average of 3.2 grafts/patient. Angiograms were performed in 9 patients (33.33 %). There were no operative mortalities. None of the patients required conversion to cardiopulmonary bypass or midsternotomy.
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INTRODUCTION
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Surgery for coronary artery disease is rapidly evolving to provide maximum benefit to the patient, in terms of freedom from symptoms and the need for reoperations. Conventional surgery with cardiopulmonary bypass (CPB) is rapidly making way for off-pump surgery and arterial conduits are being used more frequently. The trend towards complete revascularization is becoming the aim. Revascularization via left thoracotomy has previously been confined to the left anterior descending artery (LAD) and its diagonal branch or the obtuse marginal (OM) branches of the left circumflex artery. This leads to an increase in the hybrid procedures for the right coronary artery territory and/or circumflex artery.1 This study describes a method of achieving multivessel complete revascularization using arterial conduits via the left thoracotomy approach.
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PATIENTS AND METHODS
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Between January 2000 and December 2001, multivessel total arterial revascularization through anterolateral thoracotomy was performed in 27 patients, out of 803 cases of coronary artery bypass graftings (CABG). Inclusion criteria were: a thin build, age group between 40 and 60 years, good vessel calibre on preoperative angiograms and an ejection fraction of more then 40%. Patients with single vessel disease were excluded from the study. Twenty patients (74.07%) had triple vessel disease and seven patients (25.93%) had double vessel disease.
Following intubation under general anesthesia, patients were placed in supine position and a pad was placed beneath the shoulder and the hip on the left-side, to roll the patient approximately 20 degrees upward. The radial artery was removed. The left anterolateral thoracotomy was performed via the fourth intercostal space with an incision size between 10 and 15 cm. The left internal mammary artery (LIMA) was dissected at the lateral musculophrenic and medial superior epigastric branch. Heparin was used at a dose of 1.5 mg·kg-1 body weight (to maintain the activated clotting time double of the normal).
The radial artery was anastomosed to the LIMA in ‘Y’ fashion with a 7/0 polypropylene suture (Ethicon, Somerville, NJ, USA). The LIMA was anastomosed to the LAD with a 7/0 polypropylene suture. The left radial artery was sequentially anastomosed to the diagonal/marginal/posterior descending artery/posterolateral branch depending on the lesion. For better exposure the right pericardial incision was extended in inverted ‘T’ fashion. Two deep pericardial retraction sutures were placed; firstly, two-thirds of the way from apex of the pericardium to the base of the heart, and secondly, two-thirds of the way from left inferior pulmonary vein to the inferior vena cava. For exposure of anterior vessels, both the deep pericardial retraction sutures were pulled towards the patient’s left. The posterior descending artery and inferior surface vessels were pulled towards the caudal. For grafting lateral surface vessels, deep pericardial retraction sutures were pulled towards the left first and thereafter towards the caudal.
Proximal occlusion with the back of the forceps and intracoronary shunt (Chase Medical Corporation, Texas, USA) was used to facilitate the anastomosis. An Octopus (Medtronics Inc., Minneapolis, MN, USA) stabilizing device was used in all the cases. It is usually best positioned when aimed superiorly from the inferiorly placed retractor bar for the left anterior descending artery and circumflex artery. For the posterior descending artery it is positioned in the opposite direction.
Heparin was neutralized with protamine sulphate after the procedure. Electrocardiogram (ECG) and hemodynamic monitoring was performed and any alteration was managed with ionotropes. Hemostasis was secured and the thoracotomy incision was closed after inserting the chest tube (Figure 1
). A total of 87 anastomoses were performed with an average of 3.2 grafts/patients.
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Figure 1. Operative photograph of the patient showing the anterolateral thoracotomy incision after CABG.
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RESULTS
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There were no ECG changes of perioperative myocardial infarction or any rise of the MB fraction of creatine phosphokinase in these patients. Conversion to cardiopulmonary bypass or to sternotomy was not required in any patients. Only one unit of blood was used in 8 (29.62%) patients, the rest did not require blood transfusion. The ventilation time was less than 4 hours. Postoperative arrhythmia was present in 3 (11.11%) patients, mainly on the 1st and 2nd postoperative days. These arrhythmias responded to pharmacotherapy. Mild to moderate ionotropic support was required in 4 (14.81%) cases. Mean postoperative length of hospital stay was 4.4 ± 1.5 days. None of the patients had wound infections and there were no mortalities. Check angiograms were performed in 9 (33.33 %) willing patients (Figure 2). All the grafts are patent. Patients were followed up for 1 to 20 months. None of the patients died during this period and there was improvement in functional status of all the patients.
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Figure 2. Arteriogram of the left coronary artery in left anterior oblique caudal view showing patent LIMA  LAD (1), left radial artery hanged ‘Y’ on LIMA (2) and left radial artery to obtuse marginal artery (3) through left anterolateral thoracotomy incision.
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DISCUSSION
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The point of criticism against the left thoracotomy approach has been the inability to revascularize all the target vessels, especially the circumflex and/or right coronary artery territory. We have shown that it is possible via this approach albeit by a slightly larger incision in comparison to the minimally invasive direct coronary artery bypass grafting (MIDCAB) incision.2,3 With angiographic results available from many series, the quality of anastomosis on beating heart revascularization need not be questioned as they showed good and comparable patency rates.1,4,5 The avoidance of CPB is the greatest benefit to the patient, second only to a satisfactory revascularization. A decrease in morbidity for reoperative CABG done via minimally invasive method versus the conventional method have been reported.6,7
Detter and colleagues have compared the median sternotomy approach and the anterolateral thoracotomy approach.2 They demonstrated good results, with low hospital mortality and morbidity with good angiographic results, although they demonstrated longer time of surgery and coronary occlusion with a tendency towards higher risk of conversions and wound infection.
The aim of our discussion is to demonstrate the feasibility of complete revascularization with arterial conduits via the thoracotomy approach. We do not intend to compare the median sternotomy approach with the anterolateral thoracotomy approach but this approach is useful and cosmetic for primary and re-do CABG. A prerequisite of this approach is a good LIMA and a slightly longer radial artery to rotate this artery up to the right coronary territory. The limitation at present may be a longer length of incision to obtain adequate exposure. The length of the incision can be decreased with experience. The procedure did not require any conversions to sternotomy and there were no perioperative deaths or myocardial infarction, as also reported by others.4,6
In conclusion, complete revascularization is possible via this approach without compromising the safety of the procedure and the quality of the anastomosis.
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REFERENCES
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- Lloyd CT, Calafiore AM, Wilde P, Ascione R, Paloscia L, Monk CR, et al. Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization. Ann Thorac Surg
1999;68:908–11.[Abstract/Free Full Text]
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2001;19:464–70.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
