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SECTION 7 Technical aspects ofcoronary artery bypass graft surgery358
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7. Falk V, Loulmet D, Wolf RK. Procedural guide. Robotically assisted IMA harvest. Mountain View, CA:Intuitive Surgical, 2001.
8. Boyd WD, Kiaii B, Novick RJ, Rayman R, Ganapathy S, Dobkowski WB, etal. RAVECAB:improving outcome in o­pump minimal access surgery with robotic assistance and video enhancement. Can J Surg. 2001;44(1):45– 50.
9. Kiaii B, McClure RS, Stitt L, Rayman R, Dobkowski WB, Jablonsky G, etal. Prospective angiographic comparison of direct, endoscopic, and telesurgical approaches to harvesting the internal thoracic artery. Ann orac Surg. 2006;82(2):624– 8.
10. Mohr FW, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, etal. Computer- enhanced 'robotic'cardiac surgery:experience in 148 patients. J orac Cardiovasc Surg. 2001;121(5):842– 53.
11. Kiaii B, McClure RS, Stewart P, Rayman R, Swinamer SA, Suematsu Y, etal. Simultaneous integrated coronary artery revascularization with long- term angiographic follow- up. J orac Cardiovasc Surg. 2008;136(3):702– 8.
12. Halkos ME, Liberman HA, Devireddy C, Walker P, Finn AV, Jaber W, etal. Early clinical and angiographic outcomes aer robotic­assisted coronary artery bypass surgery. J orac Cardiovasc Surg. 2014;147(1):179– 85.
13. Buehler AM, Ferri C, Flato UA, Fernandes JG. Robotically assisted coronary artery bypass graing:a systematic review and meta­analysis. Int J Med Robot Comput Assist Surg. 2015;11(2):150– 8.
14. Cao C, Indraratna P, Doyle M, Tian DH, Liou K, Munkholm­Larsen S, etal. A systematic review on robotic coronary artery bypass gra surgery. Ann Cardiothorac Surg. 2016;5(6):530– 43.
15. Giambruno V, Chu MW, Fox S, Swinamer SA, Rayman R, Markova Z, etal. Robotic- assisted coronary artery bypass surgery:an 18- year single- centre experience. Int J Med Robot Comput Assist Surg. 2018;14(3):e1891.
16. Poston RS, Tran R, Collins M, Reynolds M, Connerney I, Reicher B, etal. Comparison of economic and patient outcomes with minimally invasive versus traditional o- pump coronary artery bypass graing techniques. Ann Surg. 2008;248(4):638– 46.
17. Tarola CL, Al- Amodi HA, Balasubramanian S, Fox SA, Harle CC, Iglesias I, etal. Ultrafast track robotic- assisted minimally invasive coronary artery surgical revascularization. Innovations (Phila). 2017;12(5):346– 50.
18. de Cannière D, Wimmer- Greinecker G, Cichon R, Gulielmos V, Van Praet F, Seshadri- Kreaden U, etal. Feasibility, safety, and ecacy of totally endoscopic coronary artery bypass graing:multicenter European experience. J orac Cardiovasc Surg. 2007;134(3):710– 6.
19. Schachner T, Feuchtner GM, Bonatti J, Bonaros N, Oehlinger A, Gassner E, etal. Evaluation of robotic coronary surgery with intraoperative gra angiography and postoperative multislice computed tomography. Ann orac Surg. 2007;83(4):1361– 7.
20. Bonatti J, Schachner T, Bonaros N, Oehlinger A, Wiedemann D, Ruetzler E, etal. Eectiveness and safety of total endoscopic le internal mammary artery bypass gra to the le anterior descending artery. Am J Cardiol. 2009;104(12):1684– 8.
21. Bonatti J, Schachner T, Bonaros N, Ohlinger A, Danzmayr M, Jonetzko P, etal. Technical challenges in totally endoscopic robotic coronary artery bypass graing. J orac Cardiovasc Surg. 2006;131(1):146– 53.
22. Srivastava S, Gadasalli S, Agusala M, Kolluru R, Barrera R, Quismundo S, etal. Beating heart totally endoscopic coronary artery bypass. Ann orac Surg. 2010;89(6):1873– 9.
23. Balkhy HH, Wann LS, Arnsdorf SE, Maciolek K. Long term patency evaluation of the Cardica c- port distal anastomotic
device in coronary bypass graing:initial experience in 91 gras. Presented at 12th Annual Scientic Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, San Francisco, CA, June 3– 6, 2009.
24. Seco M, Edelman JJB, Yan TD, Wilson MK, Bannon PG, Vallely MP. Systematic review of robotic- assisted, totally endoscopic coronary artery bypass graing. Ann Cardiothorac Surg. 2013;2(4):408– 18.
25. Argenziano M, Katz M, Bonatti J, Srivastava S, Murphy D, Poirier R, etal. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass graing. Ann orac Surg. 2006;81(5):1666– 74.
26. Dhawan R, Roberts JD, Wroblewski K, Katz JA, Raman J, Chaney MA. Multivessel beating heart robotic myocardial revascularization increases morbidity and mortality. J orac Cardiovasc Surg. 2012;143(5):1056– 61.
27. Bonaros N, Schachner T, Wiedemann D, Oehlinger A, Ruetzler E, Feuchtner G, etal. Quality of life improvement aer robotically assisted coronary artery bypass graing. Cardiology. 2009;114(1):59– 66.
28. Currie ME, Romsa J, Fox SA, Vezina WC, Akincioglu C, Warrington JC, etal. Long- term angiographic follow- up of robotic- assisted coronary artery revascularization. Ann orac Surg. 2012;93(5):1426– 31.
29. Bonatti JO, Zimrin D, Lehr EJ, Vesely M, Kon ZN, Wehman B, etal. Hybrid coronary revascularization using robotic totally endoscopic surgery:perioperative outcomes and 5- year results. Ann orac Surg. 2012;94(6):1920– 6.
30. Giambruno V, Jones P, Khaliel F, Chu MW, Teefy P, Sridhar K, etal. Hybrid coronary revascularization versus on­pump coronary artery bypass graing. Ann orac Surg. 2018;105(5):1330– 5.
31. Harskamp RE, Bagai A, Halkos ME, Rao SV, Bachinsky WB, Patel MR, etal. Clinical outcomes aer hybrid coronary revascularization versus coronary artery bypass surgery:a meta­analysis of 1,190 patients. Am Heart J. 2014;167(4):585– 92.
32. Bonatti J, Lehr EJ, Schachner T, Wiedemann D, Weidinger F, Wehman B, etal. Robotic total endoscopic double- vessel coronary artery bypass graing- - state of procedure development. J orac Cardiovasc Surg. 2012;144(5):1061– 6.
33. Trejos AL, Ross I, Scalesse C, Patel RV, Naish MD, Kiaii B. Preoperative evaluation of patient anatomy to increase success of robotics- assisted bypass surgery. Innovations (Phila). 2010;5(5):335– 40.
34. Escoto A, Trejos AL, Patel RV, Goela A, Kiaii B. Anatomy­based eligibility measure for robotic- assisted bypass surgery. Innovations (Phila). 2014;9(5):349– 53.
35. Christidis NK, Fox SA, Swinamer SA, Bagur R, Sridhar K, Lavi S, etal. Reason and timing for conversion to sternotomy in robotic­assisted coronary artery bypass graing and patient outcomes. Innovations. 2018;13(6):423– 7.
36. Neumann FJ, Sousa- Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, etal. 2018 ESC/ EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87– 165.
37. Lee JD, Bonaros N, Hong PT, Koer M, Srivastava M, Herr DL, etal. Factors inuencing hospital length of stay aer robotic totally endoscopic coronary artery bypass graing. Ann orac Surg. 2013;95(3):813– 8.
38. Suyker WJL, Borst C. Coronary connector devices:analysis of 1,469 anastomoses in 1,216 patients. Ann orac Surg. 2008;85(5):1828– 36.
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51
Hybrid coronaryrevascularization
Michael O. Kayatta, Henry A. Liberman, and Michael E. Halkos
Introduction
drug- eluting stents and bare- metal stents and improved safety proles compared to rst- generation drug- eluting stents.
Traditionally, the treatment of coronary artery disease has been divided among medical therapy, percutaneous coronary interven­tion (PCI), or coronary artery bypass graing (CABG). However, with hybrid coronary revascularization (HCR), both PCI and CABG are utilized to treat dierent lesions in the same patient; the goal being to take advantage of the benets of each procedure while minimizing their limitations. is chapter will discuss the advantages and disadvantages of HCR, patient selection, and the various techniques and strategies used in successful HCR programmes.
Hybrid coronaryrevascularization
e Society of oracic Surgeons database denes HCR as a pro­cedure in which both CABG and PCI are performed during the same admission, whether as planned or unplanned procedures, and including any CABG approach including full sternotomy. Amore specic standardized denition has been proposed in which HCR is dened as a planned combination of surgical and percutaneous techniques in two dierent coronary territories, both scheduled and
Comparing CABG and percutaneous coronaryintervention
In CABG, the le internal thoracic artery (LITA) is typically anas­tomosed to the le anterior descending artery (LAD), with the re­mainder of bypasses typically performed with saphenous vein gras. While LITA- to- LAD patency is greater than 90% at 10years, up to 25% of saphenous vein gras fail within the rst year and 50% of saphenous vein gras may fail within 10years. Although some surgeons have adopted a multi- arterial graing strategy based on observational data that supports improved patency and long- term mortality with bilateral internal thoracic arteries and radial artery conduits, this strategy currently has not been widely adopted into practice.
Compared to PCI, CABG is associated with improved long- term survival, greater completeness of revascularization, better long­term relief from angina, and lower repeat revascularization in pa­tients with multivessel disease. However, periprocedural morbidity is signicantly lower with PCI compared to CABG, including lower rates of stroke, atrial brillation, blood transfusions, and other complications.
While the use of bare- metal stents was associated with relatively high rates of restenosis and stent thrombosis, drug- eluting stents have im­proved the ecacy and safety of PCI. Second- generation drug- eluting stents may oer superior ecacy compared to both rst- generation
performed within a dened period. is denition more accurately reects HCR as practised in most centres and as described in this chapter.
Advantages ofHCR
A revascularization strategy combining PCI and CABG has several potential benets. By performing a minimally invasive surgical ap­proach, the complications and morbidity of CABG can be poten­tially minimized. Cardiopulmonary bypass is usually avoided, and the risk of stroke may be greatly reduced by completely avoiding aortic manipulation. Importantly, the major benet of CABG, the LITA– LAD gra, is still provided.
Due to the decreased invasiveness of HCR, shorter recovery times are typical with HCR compared to traditional CABG. Complex LAD disease is particularly challenging with PCI, and the LITA- to- LAD performed as part of HCR can provide deni­tive treatment for the LAD. Carefully selected high- risk patients for traditional CABG may also benet from the less invasive strategy of HCR by avoiding cardiopulmonary bypass, aortic ma­nipulation, and sternotomy.
Disadvantages ofHCR
e main disadvantage associated with HCR is the low adoption rate and greater required expertise associated with minimally invasive CABG. Similar to other non- sternotomy approaches for cardiac sur­gery, learning curves must be overcome, LITA– LAD patency must
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be comparable to sternotomy approaches, and procedural times should be comparable if not improved. Furthermore, HCR patients undergo two procedures (PCI and CABG), and the costs associated with this approach need to be considered. At the authors’ institution, the increased procedural costs have been oset by the decreased postoperative costs.
Patientselection
Patients with complex LAD disease not easily amenable to PCI and less complex disease in non- LAD vessels may benet from HCR. In current series, patients most commonly have two- vessel disease. However, patients with three- vessel disease may also be eligible, es­pecially if they present with focal, non- complex lesions in the cir­cumex and/ or right coronary artery territories. High operative risk with conventional CABG and poor non- LAD bypass targets are also reasons to consider HCR over conventional surgery. One meta- analysis showed that the average ejection fraction of patients undergoing HCR was 55%, with a SYNTAX score of 24– 35 (inter-
Fig.51.1 Port placement for robotic LIMA harvest.
mediate). It is important to note that presently the type of patients who are oered HCR in centres that perform HCR are treated with multivessel PCI in centres that do not perform HCR. us, in most hybrid centres, most HCR is not a substitute for multivessel CABG, but rather a substitute for multivessel PCI.
HCR patients must be eligible for minimally invasive CABG. Patients with adhesions from previous le chest surgery or large body habitus increase the diculty of the procedure. e LAD itself must be appropriate for a minimally invasive approach; a small or calcied target vessel or intramyocardial LAD may greatly increase the diculty of the procedure. While these factors are not absolute contraindications, they should be carefully weighed by the Heart Team to decide if the patient would most benefit from HCR.
Box 51.1 summarizes common contraindications to HCR.
Roboticapproaches
Two robotic approaches are commonly used in HCR:robotic- assisted MIDCAB and total endoscopic coronary artery bypass (TECAB). In both approaches, the da Vinci® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) is used. Aer placing a camera port laterally, typically in the fourth intercostal space, working ports are placed superiorly and inferiorly, typically in the second and sixth inter­costal spaces (Fig. 51.1). From the console, the surgeon then har­vests the LITA from the chest wall (Fig. 51.2) and divides it distally. Monopolar and bipolar cautery are used, and branches can also be divided with robotically applied clips.
e pericardium is opened and the LAD identied. In robotic­assisted MIDCAB, a precision non- rib- spreading thoracotomy is next made directly over the LAD at the planned site of anastomosis.
Minimally invasive surgicalapproaches
Minimally invasive direct coronary arterybypass
e LITA- to- LAD anastomosis is performed using a minimally in­vasive coronary stabilizer introduced through the inferior port site.
In minimally invasive direct coronary artery bypass (MIDCAB), a small anterolateral thoracotomy is used which allows exposure of the heart as well as the LITA, though some centres use a hemi­sternotomy. Aspecialized retractor is used which both spreads the ribs and elevates the cranial ribs to better expose the LITA. Under direct visualization, the LITA is then harvested from the chest wall. Next, the pericardium is divided, the LAD identied, and a hand­sewn LITA- to- LAD anastomosis is facilitated by using an o- pump coronary stabilizer. Both on- and o- pump approaches have been described.
Box 51.1 Contraindications toHCR
• High complexity of coronary disease.
• Unstable patients/ cardiogenic shock.
• Intramyocardial, calcified, or poor LAD target for LITA grafting.
• Left pleural adhesions.
• Large body habitus.
Fig.51.2 Robotic harvest of LIMA.
using endoscopic techniques, which can be performed with or
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without cardiopulmonary bypass. Fig. 51.3 demonstrates a patient’s skin incisions aer recovery from robotic- assisted MIDCAB.
Fig. 51.4 shows a postoperative angiogram of a LITA– LAD gra
performed by robotic- assisted MIDCAB.
36151 Hybrid coronaryrevascularization
Timing ofsurgery and percutaneous coronary intervention
Timing of procedures in HCR can be broadly grouped into three categories:concomitant or one- stage, staged with CABG rst, and staged with PCI rst. Amajority of HCR procedures are staged with minimally invasive CABG most commonly performed rst. e general rule for patients undergoing HCR is to treat the culprit or most critical coronary lesion rst.
e concomitant approach can only be performed in centres with a fully equipped hybrid operating room. Most commonly, minim­ally invasive CABG is completed rst and is immediately followed by PCI. e advantages of this approach are one procedural set­ting for the patient and immediate assessment of LITA- to- LAD pa­tency. e major disadvantages are challenges in the management of anticoagulation and antiplatelet therapy during both procedures and logistical challenges related to scheduling and timing of two dif­ferent specialist teams.
In patients with acute coronary syndromes, performing PCI rst has the advantage of treating the non- LAD culprit lesion immedi­ately to eliminate the risk of ongoing ischaemia. e patient can then safely undergo minimally invasive CABG, either during the initial
Fig.51.3 Postoperative skin incision after robotic- assisted MIDCAB.
Conversely, in TECAB, the LITA- to- LAD anastomosis is completed
hospitalization or weeks to months later, depending on the severity of LAD disease. Depending on whether or not a drug- eluting stent is used, this may require that minimally invasive LITA- to- LAD graing be performed on dual antiplatelet therapy. In the authors’ experience, robotic- assisted MIDCAB is feasible and safe with pa­tients on aspirin plus clopidogrel, despite a slightly higher risk of reoperation for bleeding and higher chest drainage. Table 51.1 sum- marizes these potential advantages and disadvantages.
Fig.51.4 LITA angiography after robotic- assisted MIDCAB
LITA– LAD graft.
Outcomes
Developing a successful HCR programme requires a multidiscip­linary team eort to be successful and is dependent on a collabora­tive environment to oer a unique treatment option for carefully selected patients with multivessel disease. In addition, dedicated anaesthesia and operating room and catheterization laboratory per­sonnel are important to ensure successful procedural outcomes with minimally invasive CABG and PCI (Fig. 51.5).
e majority of the evidence to date supporting HCR comes from single institutional series. At the authors’ institution, operative mortality is less than 1%, perioperative stroke is comparable to PCI at 0.6%, and the mediastinitis rate has been zero. However, several studies have also shown slightly higher repeat revascularization events in patients treated with HCR compared to CABG, due to in­creased repeat interventions in PCI- treated vessels. Amulticentre observational trial showed no dierence in major adverse car­diac and cerebrovascular evens (MACCE) at 1year between HCR
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Table51.1 Sequence ofprocedures inHCR
Advantages Disadvantages
Concomitant
Possibly improved patient satisfaction Immediate interrogation of anastomosis
CABG first (staged)
Surgeon and interventional cardiologist can perform their respective procedures according to standard anticoagulation and antiplatelet protocols Angiographic assessment of ITA– LAD graft is performed during subsequent PCI
PCI first (staged)
Non- LAD culprit lesion treated first in patients presenting with an acute coronary syndrome If PCI unsuccessful, can refer patient for conventional CABG
Concern for postoperative bleeding due to antiplatelet and anticoagulant medications Logistical challenges
Incomplete revascularization at the completion of surgical stage Requires additional procedure
Concerns for bleeding in CABG operation due to dual antiplatelet therapy Possible increased risk of stent thrombosis from hypercoagulable state associated with surgery No angiographic assessment of graft patency
and multivessel PCI; a subsequent multicentre randomized trial began in 2017 comparing HCR to PCI for patients with multivessel coronary disease, but NIH funding was withdrawn in 2019 due to slow recruitment of patients. One randomized study has been conducted which compared HCR (MIDCAB) to conventional CABG in 200 patients. MACCE were not dierent between groups at 1year (89.8% HCR vs 92.2% conventional CABG), and LITA­to- LAD patency was also comparable at 94% vs 93%. At 5- year follow- up in the same randomized controlled trial, all- cause mor­tality was similar between groups (6.4% in HCR vs 9.2% in CABG; P= 0.69), as were rates of myocardial infarction (4.3% in HCR vs 7.2% in CABG; P =0.30), repeat revascularization (37.2% in HCR vs 45.4% in CABG; P=0.38), stroke (2.1% in HCR vs 4.1% in CABG; P=0.35), and MACCE (45.2% in HCR vs 53.4% in CABG;
Conclusion
HCR has evolved as a ‘best of both worlds’ approach for the treat­ment of selected patients with multivessel disease, the large majority of whom would otherwise be treated with multivessel PCI. In pa­tients with non- LAD disease amenable to PCI and LAD disease amenable to minimally invasive LITA– LAD graing, HCR repre­sents a viable alternative for revascularization. ere are currently several minimally invasive surgical techniques, and all have been shown to be successful among experienced surgeons. Implementing a hybrid programme will provide an additional treatment option for selected patients with multivessel coronary disease and oers those patients the life- prolonging benet of LITA– LAD graing.
P=0.39).
Surgeon
Organizational
Support
OR
Team
HCR
Interventional
Cardiologist
Non-Invasive
Cardiologist
Critical Care
Team
Fig.51.5 Components of a successful HCR programme. OR, operating
room/ theatre.
Anaesthesia Team
REFERENCES
1. Harskamp RE, Bonatti JO, Zhao DX, Puskas JD, De Winter RJ, Alexander JH, etal. Standardizing denitions for hybrid coronary revascularization. J orac Cardiovasc Surg. 2014;147(2):556– 60.
2. Harskamp RE, Bagai A, Halkos ME, Rao SV, Bachinsky WB, Patel MR, etal. Clinical outcomes aer hybrid coronary revascularization versus coronary artery bypass surgery:a meta­analysis of 1,190 patients. Am Heart J. 2014;167(4):585– 92.
3. Puskas JD, Halkos ME, Derose JJ, Bagiella E, Miller MA, Overbey J, etal. Hybrid coronary revascularization for the treatment of multivessel coronary artery disease:a multicenter observational study. J Am Coll Cardiol. 2016;68(4):356– 65.
4. Gasior M, Zembala MO, Tajstra M, Filipiak K, Gierlotka M, Hrapkowicz T, etal. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7(11):1277– 83.
5. Tajstra M, Hrapkowicz T, Hawranek M, Filipiak K, Gierlotka M, Zembala M, etal. Hybrid coronary revascularization in selected patients with multivessel disease:5- year outcomes of the prospective randomized pilot study. J Am Coll Cardiol Intv. 2018;11(9):847– 52.
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52
Surgical techniques tobypass diffuse coronarydisease
Toshihiro Fukui and Shuichiro Takanashi
Introduction
With the recent and rapid advances in percutaneous coronary inter­vention, the rate of high- risk patients with severe disease referred for coronary artery bypass graing (CABG) has been increasing. Among these patients are those with diusely diseased coronary arteries, including severe calcications or so plaques in the vessel wall. Coronary endarterectomy has been used to treat severely or diusely diseased coronary arteries since the 1950s. However, early experiences with this method were not satisfactory in terms of the clinical results compared with conventional bypass graing.,
Long segmental reconstruction with or without endarterectomy has been used as an alternative to conventional bypass graing to treat severely or diusely diseased coronary arteries.–  e ad­vantage of this method is that the myocardium supplied by the side branches of the diusely diseased coronary segment can be revascularized. is advantage cannot be achieved with conven­tional graing to the distal le anterior descending artery (LAD) alone because it would not perfuse the diseased and more proximal segments. Concomitant endarterectomy with plaque removal is per­formed if the plaque includes hard diuse calcication.
As surgical techniques and technologies have evolved, the benets of long segmental reconstruction with or without endarterectomy for the treatment of the diseased LAD have gradually become recog­nized. us, today, long segmental reconstruction with or without endarterectomy complements conventional bypass graing as a sur­gical revascularization method for patients with diusely diseased coronary arteries. In this chapter, we review the technical aspects and outcomes of this surgical method.
Indications
Long segmental reconstruction with or without endarterectomy is usually performed for diusedly diseased coronary arteries that have long segmental stenoses because of severe calcication or atheroma­tous plaque, especially in diusely diseased distal vessels with lu­minal diameters less than 1.5mm, as determined on preoperative
angiography. Occasionally, the decision to perform long segmental reconstruction with endarterectomy is made intraoperatively, when a normal anastomosis cannot be carried out because of the presence of large so plaques, which would be at high risk of distal embolism following their rupture. More commonly, endarterectomy is per­formed because of hard, diuse calcied plaque. ese situations sometimes cannot be anticipated by preoperative angiography. With endarterectomy, an anastomosis site can be obtained when there are complex intimal lesions, severe calcications, or so plaques, all of which rule out the establishment of typical anastomoses.
e target artery for performing long segmental reconstruction is most commonly the LAD. Long segmental reconstruction of a dif­fusely diseased LAD has the advantage of providing a blood supply to the diagonal and septal arteries, which can relieve ischaemia in the anterior and septal territories of the heart. e advantage of long segmental reconstruction with or without endarterectomy of the LAD over conventional bypass graing is particularly important be­cause incomplete revascularization is a predictor of a higher mor­tality rate aer CABG. By contrast, long segmental reconstruction with or without endarterectomy of the le circumex or right cor­onary artery is less commonly performed because the patency rates of these vessels are worse than that of the LAD.
We do not perform long segmental reconstruction when the my­ocardium supplied by the target vessel has no viability due to large areas involved by previous myocardial infarction. us, preopera­tive myocardial viability testing is performed in patients with areas of akinetic or dyskinetic myocardium due to its supply by diusely diseased arteries.
Techniques oflong segmentalreconstruction
Withendarterectomy
Atheroma and calcication in the middle LAD can be observed by inspection from the adventitia. Coronary endarterectomy is performed manually, without the use of forced carbon dioxide or excimer laser. e manual techniques consist of closed and open methods. Closed endarterectomy is carried out by traction of the
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distal endarterectomized intima through a small proximal arteri­otomy. is method is relatively fast but it has several disadvantages, including possible severance of the diagonal branches and septal perforators and occlusion of the distal end of the lumen by a dis­section, due to an insucient endarterectomy. e open method is more time- consuming but the openings of the side branches and the distal end of the LAD can be observed directly. We therefore prefer the open method with a long segmental incision rather than the closed traction- counter traction method (Fig. 52.1).,
In the open method as performed by our group, the incision is initially made in the middle, but relatively distal, portion of the LAD and then extended proximally and distally. e atheromatous core is carefully dissected from the adventitia with a ne spatula and for­ceps. All side branches involved in the atheroma are observed dir­ectly and their intimae are carefully dissected and removed. e proximal atheromatous core is sharply divided to avoid removing the most proximal stenotic lesion. e distal end of the atheroma­tous core is also sharply divided at the intact intima, with the distal side completed before the intimal diameter tapers to less than 1mm. e posterior wall of the divided intima of the distal LAD is tacked
with 8- 0 polypropylene sutures. Saline irrigation is performed on the adventitial surface to remove the fragments of atheromatous core or media as these can be the cause of distal embolism.
e incised part of the LAD is reconstructed using the in situ le interior thoracic artery (LITA). Due to its superior patency rate, we prefer using the LITA rather than a saphenous vein gra or other arterial gras. e LITA is dissected in a skeletonized fashion and incised to match the length of the LAD. Long reconstruction of the incised LAD using the LITA is performed with several 8- 0 and 7­0 polypropylene sutures. First, the proximal LAD and the heel of the LITA are anastomosed using the parachute technique and an 8- 0 polypropylene suture. e distal LAD and the toe of the LITA are then anastomosed to match the length of the latter artery, again using 8- 0 polypropylene suture. Next, the two sides of the LITA and LAD are anastomosed using 7- 0 polypropylene sutures. During LITA anastomosis, care must be taken not to injure the side branches of the LAD.
CABG without cardiopulmonary bypass (o- pump) is our rst choice for surgical revascularization. Other investigators have dem­onstrated that endarterectomy without cardiopulmonary bypass can
Fig.52.1 Intraoperative photographs of long segmental reconstruction with endarterectomy. (a)Along incision with endarterectomy of the left
anterior descending artery. (b)The reconstruction includes a long segmental patch anastomosis achieved using the left internal thoracic artery. (c)Aspecimen of the endarterectomized core.
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managed with antiplatelet and anticoagulation agents. Intravenous heparin is started when the drainage from the mediastinum is less than 100 mL/ hour. Low- dose aspirin (100 mg/ day) and clopidogrel (75 mg/ day) are prescribed beginning the day aer surgery, at which time warfarin, maintained with a target international normalized ratio of 2.0, is also started. Intravenous heparin is continued until the target international normalized ratio is achieved. Warfarin and clopidogrel administration are stopped aer 3 and 12months re­spectively but aspirin is continued indenitely in all patients.
In patients without endarterectomy, early occlusion rarely oc­curs. However, intravenous heparin is administered for several days. Low- dose aspirin and clopidogrel are prescribed similar to a case of endarterectomy.
Early postoperative angiography is performed during the same hospitalization to conrm gra patency in all patients who provided informed consent. Angiography is carried out 1year postoperatively.
Fig.52.2 Intraoperative photographs of long segmental reconstruction
without endarterectomy. The reconstruction includes a long segmental patch anastomosis with plaque exclusion achieved using the left internal thoracic artery.
Early and long- term clinicaloutcomes
Historically, postoperative mortality and morbidity following end­arterectomy were high (up to 9%). However, with advances in
be performed safely. However, patients with severely impaired le ventricular function, intramyocardial coronary arteries, or redo sur­gery will require on- pump CABG.
Withoutendarterectomy
e initial incision is initially made in the distal portion of the LAD and then extended proximally and distally (Fig. 52.2). e anterior wall of the LAD with atheromatous core is carefully incised lon­gitudinally towards the proximal side. is longitudinal incision should be kept in the middle of the anterior wall of the LAD as far as possible. e proximal end of the incision is stopped at the rela­tively normal intima. e distal end of the incision is also stopped at the intact intima, with the distal side completed before the intimal diameter reaches 1mm.
e incised part of the LAD is reconstructed using the in situ skel­etonized LITA. is method is fundamentally almost the same as the technique described previously for the long segmental reconstruc­tion with endarterectomy. Long reconstruction of the incised LAD using the LITA is performed with several 8- 0 and 7- 0 polypropylene sutures. e anastomoses between the LITA and the proximal and distal LAD are performed using 8- 0 sutures. e two sides of the LITA and LAD are anastomosed using 7- 0 polypropylene sutures. During side anastomoses, plaque is excluded from the inside of the
surgical technique and perioperative management, endarterec­tomy is considered to be a safe procedure and the outcomes are favourable., In their meta- analysis, Wang et al. evaluated the early and long- term outcomes of patients undergoing endarter­ectomy. Overall mortality was 5.4%, but the rates reported aer 2000 (4.3%) were better than those reported before 2000 (5.9%). In our experience, patients undergoing endarterectomy have a mortality rate of 2.7%, similar to that determined by other inves­tigators., On the other hand, the early mortality rate of long segmental reconstruction without endarterectomy was 1.3% in our experience. e higher mortality rate associated with end­arterectomy than with isolated CABG may be attributed to the role played by associated comorbidities and risk factors rather than to the endarterectomy per se.
According to the previously mentioned meta- analysis, the long- term survival rate of patients undergoing endarterectomy is similar to that of patients treated by isolated CABG (hazard ratio
1.16, 95% condence interval 0.32– 4.22; P=0.82). In our experi­ence, the overall 10- year survival rate and the freedom from major adverse cardiac events in patients undergoing long segmental re­construction with endarterectomy are 74.9% and 89.5% respect­ively. ese results were comparable to those in patients without endarterectomy (73.6% and 70.4%).
anastomosis line. is means that the new lumen is created by the LITA and the less diseased coronary artery. All side branches of the LAD are included in the new lumen.
Angiographicresults
Postoperativemanagement
In patients who undergo long segmental reconstruction with end­arterectomy, the major serious complication is early occlusion of the endarterectomized vessel. is is oen as a result of local hypercoagulation related to a triggering of the coagulation cas­cade by the lack of endothelium in the early postoperative stage. Consequently, endarterectomy must be carefully and closely
Qureshi etal. reported that the early and interval patency rates of the endarterectomized artery were 83% and 75%, respectively. In the series of Goldstein etal., the early and late patency rates of the endarterectomized LAD were 100% and 75%, respectively. Nishi etal. reported that the patency rate following endarterectomy is a function of the chosen surgical method. At mid- term follow- up, the grade Apatency rates (stenosis- or occlusion- free anastomoses) obtained with the open and closed methods were 76.1% and 38.1% respectively, although the overall patency rates of the two groups
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Fig.52.3 Preoperative and postoperative angiography of the left anterior descending artery (LAD) in a patient undergoing long segmental
reconstruction with endarterectomy. (a)Preoperative angiography showing a diffusely diseased LAD. (b)Early postoperative angiography showing an endarterectomized LAD reconstructed with the left internal thoracic artery. (c)One- year angiography demonstrates the good patency.
were comparable (89.1% and 81.0%). Intravascular ultrasonog­raphy showed that the intima of the LITA became circumferential, with the growth of new intima in vessels endarterectomized using the open method. ese angiographic results support the use of the open over the closed method.
In our experience, patency rates of both the ITA and LAD were 95.7% in patients with long segmental reconstruction with or without endarterectomy. Fig. 52.3 and Fig. 52.4 show the rep­resentative cases of both procedures. However, long segmental re­construction without endarterectomy was better than that with endarterectomy (99.0% versus 92.1%; P = 0.03). Moreover, the follow- up (mean; 12.9months aer operation) patency rate of long segmental reconstruction without endarterectomy was better than that with endarterectomy (97.6 vs 89.7%; P=0.05). In patients with
a patent LAD at follow- up, no restenosis was observed in the recon­structed segment.
Conclusion
Long segmental reconstruction with or without endarterectomy of a diusely diseased LAD using the LITA is one surgical option in patients who may not be candidates for conventional CABG. is technique carries several advantages over conventional CABG. First, it creates a new intraluminal wall composed of the ITA in­tima and disease- free coronary artery wall, which may contribute to long- term patency of the reconstructed LAD. Second, the ostia of the side branches can be seen directly, which leads to a secure
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Fig.52.4 Preoperative and postoperative angiography of the left anterior descending artery (LAD) in a patient undergoing long segmental
reconstruction without endarterectomy. (a)Preoperative angiography showing a diffusely diseased LAD. (b)Early postoperative angiography showing a LAD reconstructed with the left internal thoracic artery. (c)One- year angiography demonstrates the good patency.
anastomosis without obstruction of these vessels. Asimple anas­tomosis to the distal LAD cannot obtain sucient blood supply to these important side branches. e early and long- term outcomes of patients undergoing long segmental reconstruction with or without endarterectomy have been improving, with a favourable patency rate, as demonstrated angiographically.
REFERENCES
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3. Brenowitz JB, Kayser KL, Johnson WD. Results of coronary artery endarterectomy and reconstruction. J orac Cardiovasc Surg. 1988;95(1):1– 10.
4. Barra JA, Bezon E, Mondine P, Resk A, Gilard M, Mansourati J, etal. Surgical angioplasty with exclusion of atheromatous plaques in case of diuse disease of the le anterior descending artery:2years’ follow- up. Eur J Cardiothorac Surg. 2000;17(5):509– 14.
5. Fukui T, Takanashi S, Hosoda Y. Long segmental reconstruction of diusely diseased le anterior descending coronary artery with le internal thoracic artery with or without endarterectomy. Ann orac Surg. 2005;80(6):2098– 105.
6. Prabhu AD, azhkuni IE, Rajendran S, amaran RA, Vellachamy KA, etal. Mammary artery patch reconstruction of le anterior descending coronary artery. Asian Cardiovasc orac Ann. 2008;16(4):313– 7.
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