Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial

OBJECTIVES: To evaluate the safety and effectiveness of a self-closing surgical clip with an interrupted technique in left internal thoracic artery to left anterior descending artery bypass grafting. METHODS: Eighty-two patients were enrolled and treated (February 2000 through August 2001) in a prospective, nonrandomized, multicenter trial. Left internal thoracic artery to left anterior descending artery anastomoses were performed in 60 off-pump coronary artery bypasses (73%), 12 conventional coronary artery bypass grafting (15%), and 10 minimally invasive direct coronary artery bypass (12%) procedures. Angiograms (64 to 383 days, mean 200 days) were obtained on 63 patients (77%). Qualitative and quantitative angiographic assessment was performed by an independent core laboratory. RESULTS: The self-closing surgical clip was used for 82 left internal thoracic artery to left anterior descending artery interrupted anastomoses without the requirement for knot tying or primary suture management. Minimum left internal thoracic artery to left anterior descending artery anastomosis time was 3 minutes. There was one perioperative and one late death (both not heart related) and one reexploration for bleeding unrelated to the anastomotic site. FitzGibbon grades were as follows: A (n = 60, 95.2%), B (n = 3, 4.8%) including one kinked left internal thoracic artery, and O (n = 0, 0%). Quantitative analysis (n = 57) showed mean lumen diameters of left internal thoracic artery proximal to the anastomosis of 2.1 mm, at anastomosis of 2.0 mm, and in the left anterior descending artery distal to the anastomosis of 1.9 mm. The average ratio of the anastomosis to the left anterior descending artery diameter was 1.14 (0.45 to 1.93). Anastomotic stenosis as a percentage of average left internal thoracic artery to left anterior descending artery diameter was -2.3%, comparing favorably with results (23% to 24%) reported from the Patency, Outcomes, Economics, Minimally invasive direct coronary artery (POEM) bypass study. CONCLUSIONS: The interrupted technique, facilitated by a self-closing anastomotic clip, yields favorable 6-month angiographic results when compared with other published studies.     

Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.

OBJECTIVES: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting. METHODS: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 micrograms) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts. RESULTS: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load)/(total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 +/- 29% versus 5 +/- 10%). CONCLUSIONS: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

Benefits accruing to grafting of the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting

Objectives: We have investigated the effects and outcome from grafting the right internal thoracic artery to the left anterior descending artery in coronary artery bypass grafting.Methods: We analyzed the findings in 185 patients who underwent coronary artery bypass grafting involving right internal thoracic artery-left anterior descending artery bypass. The survival rate, cardiac events related to the right internal thoracic artery-left anterior descending artery graft, and graft patency were investigated. In cardiac catheterization, the production of nitric oxide from the endothelium of the internal thoracic artery was measured as the plasma nitrite and nitrate levels by the Griess reaction. The reactions to acetylcholine infusion (5 μg) in the right internal thoracic artery (n = 4) were compared to those in the left internal thoracic artery (n = 9) grafts.Results: The hospital mortality rate was 0.5%. The actuarial survival rate at 11 years after operation was 98.81%. The rate of freedom from cardiac events at 11 years after operation was 92.08%. The rate of patency of the right internal thoracic artery-left anterior descending artery was 97.0% in 133 patients. Nitric oxide production was calculated as (total nitrite plus nitrate production in response to stimulation by acetylcholine-total nitrite plus nitrate level before acetylcholine load) / (total nitrite plus nitrate level before acetylcholine load). There was no significant difference in changes in plasma concentration in response to acetylcholine stimulation between the right internal thoracic artery-left anterior descending artery and left internal thoracic artery-left anterior descending artery groups (20 ± 29% versus 5 ± 10%).Conclusions: The right internal thoracic artery-left anterior descending artery grafts exhibited good patency and release of nitric oxide in response to acetylcholine loading, similar to left internal thoracic artery-left anterior descending artery grafts.     

Automated distal coronary bypass with a novel magnetic coupler (MVP system)

OBJECTIVE: We sought to assess the feasibility of performing sutureless distal coronary artery bypass anastomoses with a novel magnetic coupling device. METHODS: From May 2000 to April 2001, single-vessel side-to-side coronary artery bypass grafting on a beating heart was performed in 39 domestic white pigs (35-60 kg) without the use of mechanical stabilization, shunts, or perfusion bridges. Animals were divided into 2 groups. Seventeen pigs underwent right internal thoracic artery to right coronary artery bypass grafting through a median sternotomy (group 1) with a novel magnetic vascular positioning system (MVP system; Ventrica, Inc, Fremont, Calif). Twenty-two pigs underwent left internal thoracic artery to left anterior descending artery grafting with the MVP anastomotic device through a left anterior minithoracotomy (group 2). This system consists of 2 pairs of elliptical magnetic implants and a deployment device. One pair of magnets forms the anastomotic docking port within the graft; the other pair forms an identical anastomotic docking port within the target vessel. The anastomosis is created when the 2 docking ports magnetically couple. Anastomotic patency was evaluated by means of angiography during the first postoperative week and at 1 month. Histologic studies were performed at different time points as late as 6 months. RESULTS: Right internal thoracic artery to right coronary artery anastomoses and left internal thoracic artery to left anterior descending artery anastomoses were successfully performed with the system in all animals. The self-adherent and self-aligning properties of the implants allowed for immediate and secure approximation of the arteries (total anastomotic time between 2-3 minutes). Anastomoses were constructed without a stabilization platform. Five nondevice-related deaths occurred postoperatively. One-week angiography, performed in 35 surviving animals, showed a patent graft and anastomosis in all cases. The patency rate at 1 month was 97% (33/34). Histologic studies as late as 6 months demonstrated neointimal coverage of the magnets without any significant luminal obstruction. Histology also confirmed the presence of viable tissue between magnets. CONCLUSION: The MVP anastomotic system uses magnetic force to create rapid and secure distal coronary artery anastomoses, which might facilitate minimally invasive and totally endoscopic coronary artery bypass surgery.     

Initial United States clinical trial of robotically assisted endoscopic coronary artery bypass grafting

OBJECTIVES: With traditional instruments, endoscopic coronary artery bypass grafting has not been possible. This study was designed to determine the clinical feasibility of using a robotically assisted microsurgical system to create endoscopic coronary anastomoses. Methods And Results: Ten patients underwent endoscopic coronary artery bypass grafting of the left internal thoracic artery to the left anterior descending artery. Subxiphoid endoscopic ports (2 for instruments, 1 for a camera) were placed, and a robotic system was used to perform the left internal thoracic artery-left anterior descending artery bypass graft. Conventional techniques were used to perform the other grafts. Blood flow through the left internal thoracic artery graft was measured in the operating room and was adequate in 8 of 10 patients. The 2 inadequate grafts were revised successfully by hand. Six weeks after the operation, selective coronary angiography demonstrated a graft patency of 100% (8/8). There were no technical failures of the robotic system. The only postoperative complication was mediastinal hemorrhage in 1 patient. CONCLUSIONS: This pilot study demonstrates the feasibility of robotically assisted endoscopic coronary artery bypass grafting.     

Coronary artery bypass grafting without full sternotomy

Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.     

Comparative analysis of the patency of the internal thoracic artery in the CABG of left anterior descending artery: 6-month postoperative coronary CT angiography evaluation

Objective

To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively.

Methods

Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory.

Results

The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group.

Conclusion

Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site.     

Axillary-coronary artery bypass reconstruction as an alternative in coronary artery reoperations

BACKGROUND AND AIMS: The increasing incidence of reoperations in coronary surgery associated with higher perioperative risks is a challenge for refinement of the surgical methods. The aim of the work is to prove the feasibility and satisfactory intermediate results of minimally invasive axillary-coronary artery bypass reconstruction in redo coronary surgery in case the left internal mammary artery had already been harvested. MATERIAL AND METHODS: Three patients (six months, two and six years after primary coronary artery bypass grafting) admitted for redo coronary surgery because of a recurrence of angina and proven malfunction of the left internal mammary artery-left anterior descending coronary artery anastomosis. An axillary-coronary venous graft was performed via left anterior small thoracotomy (LAST) on a beating heart in all three cases. RESULTS: Excellent patency of the graft was noted on control angiography within 9 days after the procedure together with good clinical improvement in midterm follow-up. CONCLUSION: Minimally invasive axillary-coronary artery bypass via LAST access in redo coronary surgery is a good alternative in cases where the left internal mammary artery cannot be used.     

Midterm angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass

BACKGROUND: Coronary bypass surgery that provides good long-term graft patency can be performed on the beating heart as a viable alternative to conventional coronary artery bypass grafting (CABG). METHODS: From September 1993 to December 1996, 696 patients underwent CABG on the beating heart at the Ko?uyolu Heart and Research Hospital in Istanbul. Among them, 70 patients were chosen randomly for angiographic assessment of off-pump coronary artery bypass grafting. RESULTS: The interval from operation to angiography varied from 24 to 61 months (mean, 36.1+/-10.9 months). The patency rate of left internal mammary-left anterior descending artery anastomoses was 95.59% (patency achieved in 65 of 68 patients) and of vein grafts was 47.06% (patency achieved in 16 of 34 patients) (p < 0.0001). The patency rates of grafts anastomosed to the left anterior descending artery were significantly higher than the rates of the grafts anastomosed to the other coronary arteries (95.71% versus 45.45%, p < 0.0001). Multivariate analysis showed that graft type (p < 0.0001) and hyperlipidemia (p = 0.023) were significant predictors for graft occlusion. Left ventricular function improved significantly after CABG (p = 0.04). Reintervention (using percutaneous transluminal cardiac angioplasty) and reoperation rates were 0.97% and 1.4%, respectively. CONCLUSIONS: Off-pump coronary artery bypass grafting appears to produce midterm and long-term patency rates that are comparable to those of conventional techniques; that is especially true in cases of arterial conduits and of conduits anastomosed to the left anterior descending artery.     

Multivessel distal sutureless off-pump coronary artery bypass grafting procedure using magnetic connectors

Proximal anastomotic devices for beating heart coronary artery bypass grafting (CABG) have been developed to avoid ascending aortic manipulation. Distal anastomotic devices may become an extremely useful tool to assist in enabling minimally invasive (robotic) multivessel CABG. As a transition phase toward this ultimate goal we have been using a distal anastomotic device for the left internal mammary artery-left anterior descending artery (LIMA-LAD) anastomosis. In addition we recently performed two off-pump coronary artery bypass procedures that were distally completely sutureless.     

Beating heart off-pump myocardial revascularization in an infant

A 6-week-old patient weighing 4 kg was admitted for surgical correction of anomalous left coronary artery from the pulmonary artery. Reimplantation of the coronary artery with cardiopulmonary bypass was impossible because the patient also had hereditary spherocytosis, which put him at risk for hemolytic anemia. Thus, closure of the left main stem and left internal mammary artery-left anterior descending coronary artery bypass grafting were performed successfully with the heart beating.     

Beating-heart totally endoscopic coronary artery bypass grafting: Report of a case

This case report presents beating-heart totally endoscopic coronary artery bypass grafting (TECAB) for single-vessel coronary artery disease. A 72-year-old man with isolated left anterior descending (LAD) coronary artery disease was considered eligible for TECAB. Left internal thoracic artery (LITA) mobilization and subsequent off-pump revascularization applying the LITA to the LAD in a closed chest environment was performed using the da Vinci surgical system (Intuitive Surgical, Mountain View, CA, USA). The LITA was first harvested completely in a totally skeletonized fashion through three incisions 1–2 cm long in the left thoracic wall. The LAD was immobilized with the aid of a heart stabilizer. The LITA was then anastomosed to the LAD with 10 interrupted sutures of a Nitinol self-closing S15 U-clip device (Medtronic, Minneapolis, MN, USA) on the beating heart without the use of cardiopulmonary bypass. The time acquired to perform anastomosis was 20 min, and the total operative time was 5 h 34 min. The postoperative course was uneventful and the patient was discharged 5 days after the operation. Beating-heart TECAB was successfully performed for this patient with single-vessel LAD disease. This approach may be an evolutionary step toward beating-heart multivessel TECAB.     

Facilitated coronary anastomosis using a nitinol U-Clip device: bovine model

OBJECTIVE: The coronary anastomosis is the most difficult part of the coronary bypass procedure, particularly when using a minimally invasive technique. Methods to facilitate coronary anastomosis will make the minimally invasive approach to coronary bypass feasible. We sought preclinical validation and testing of the design and efficacy of a self-closing penetrating clip that can be used to facilitate the creation of graft-to-coronary end-to-side anastomosis. METHODS: The nitinol U-Clip device (Coalescent Surgical, Inc, Sunnyvale, Calif) was used in 13 consecutive calves (63-118 kg). In each animal, the device was (1) used to create an anastomosis of the right internal thoracic artery to a coronary artery with the heart beating and (2) compared to polypropylene suture when used to repair two carotid arteriotomies. Intraoperative, 1-week, 8-week, and 26-week postoperative angiograms and detailed histopathologic examinations were used to evaluate anastomotic patency and healing characteristics. RESULTS: The nitinol U-Clip device successfully created right internal thoracic artery-coronary artery anastomoses and repaired carotid arteriotomy sites in 13 consecutive calves. The clip was precisely placed by means of the integrated suture and needle in a fashion similar to that used for conventional suture. The clip met design specifications by reliable release and automatic closure, thereby eliminating knot tying and assisted suture management. At the time of harvest, angiography showed widely patent coronary anastomoses (FitzGibbon grade A criteria, n = 13) and carotid arteriotomy repair sites (n = 13). Histopathologic evaluation confirmed normal healing with smooth circumferential neointimal resurfacing at the anastomotic and repair sites. CONCLUSIONS: The nitinol U-Clip design and function was validated in the formation of bovine coronary anastomoses on the beating bovine heart with excellent graft patency and healing characteristics. The nitinol U-Clip device tests favorably when compared with conventional sutures in carotid artery repair.     

Experimental off-pump coronary bypass using a robotic telemanipulation system.

We hypothesized that a high-quality anastomosis between the left internal thoracic artery and the left anterior descending coronary artery could be constructed off-pump using a 4-degrees-of-freedom robotic telemanipulation system, endoscopic myocardial stabilization, and two-dimensional visualization. Nine swine were used. Three ports were created on the left chest for the endoscope and the two robotic arms, and another port was created on the right chest for the endostabilizer. Quality of anastomosis was assessed by angiography, analysis of flow, survival after proximal coronary ligation, and histopathology. All nine anastomoses were completed successfully in 22 +/- 3.6 minutes without the need for repair stitches. Left internal thoracic artery flow was 21.6 +/- 2.5 ml/min with diastolic dominant pattern. Eight animals (89%) survived for 60 minutes with the proximal left anterior descending coronary ligated. Angiographic patency was 100% with Fitzgibbon grade A in all. Histopathology of the anastomosis demonstrated minor changes in the integrity of the endothelium and the internal elastic lamina and absence of medial necrosis. We have demonstrated in our robotic off-pump coronary bypass model that a high-quality anastomosis can be constructed between the left internal thoracic artery and the left anterior descending coronary artery. These results support continued research towards robotic endoscopic off-pump CABG.     

Reduction in brain embolization using the Aegis aortic cannula during bypass in swine

BACKGROUND: Although robotically assisted coronary arterial anastomoses are being performed clinically, the short-term and long-term quality and integrity of the left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis remains unknown. The goal of this study was to perform a histologic and angiographic assessment of porcine beating heart LITA to LAD anastomoses using either robotic assistance or a conventional freehand technique. METHODS: Twelve pigs underwent beating heart LITA to LAD anastomoses using either the robotically assisted (n = 6) or conventional freehand techniques (n = 6). Quantitative histologic analysis was performed in all animals in order to determine the degree of vascular wall damage. Selective coronary arteriography was performed in all animals immediately after the procedure in order to evaluate anastomotic patency. The unpaired Student's t test was used for all comparisons between groups. RESULTS: There were no differences in vascular wall damage between the robotically assisted and freehand techniques. Postoperative angiography revealed no stenoses in either group. CONCLUSIONS: Use of the robotically assisted technique for creation of a LITA to LAD anastomosis was not associated with increased histologic damage when compared with the freehand technique in a beating heart porcine model. Furthermore, there was no difference between the two techniques in postoperative patency rate. These results support further clinical investigation of robotically assisted coronary bypass surgery.     

Intraoperative Angiography During Minimally Invasive Direct Coronary Artery Bypass Operations

Background. The technical demands of beating heart operations raise concerns about anastomotic patency. This feasibility study tested the usefulness of intraoperative angiography during minimally invasive direct coronary artery bypass grafting (MIDCABG).

Methods. Ten patients underwent intraoperative angiography of the internal thoracic artery (ITA) after MIDCABG. Minimally invasive direct coronary artery bypass grafting was performed on a beating heart through the fourth or fifth intercostal space. Angiography was performed through the right or left femoral artery with a 7F introducer system placed before the operation. Views were obtained in the right and left anterior oblique and straight anterior projections.

Results. There were no deaths or intraoperative morbidities related to MIDCABG or angiography. Seven patients demonstrated widely patent MIDCABG anastomoses with obliteration of all intercostals, widely patent ITA pedicles, good distal runoff, and placement of the ITA into the proper native coronary artery. Two patients had revisions of their ITA pedicles, which on repeated angiography showed correction. One patient’s procedure was converted to a sternotomy because of poor distal runoff and haziness at the level of the MIDCABG anastomosis.

Conclusions. This feasibility study demonstrates the utility of intraoperative ITA angiography in identifying problems after MIDCABG. Intraoperative angiography may facilitate MIDCABG by documenting proper placement of conduits, obliteration of intercostal vessels, and patency of the MIDCABG anastomosis and ITA pedicle.     

Endoscopic computer-enhanced beating heart coronary artery bypass grafting

Background. Telemanipulation systems have enabled coronary revascularization on the arrested heart. The purpose of this study was to develop a technique for computer-enhanced endoscopic coronary artery bypass grafting on the beating heart.

Methods. The operation was performed using the daVinci telemanipulation system. Through three ports, the left internal thoracic artery was harvested in 10 mongrel dogs (30 to 35 kg) using single right-lung ventilation and CO₂ insufflation. Through a fourth port an articulating stabilizer, manipulated from a second surgical console, was inserted to stabilize the heart. The left anterior descending artery was snared using silicone elastomer slings anchored in the stabilizer cleats and the graft to coronary artery anastomosis was performed.

Results. In 7of 10 dogs, total endoscopic beating heart bypass grafting, cardiac stabilization, arteriotomy, and arterial anastomosis were performed using computer-enhanced technology. Endoscopic stabilization and temporary left anterior descending artery occlusion were well tolerated. All grafts were patent although minor strictures were found in 2. In 3 dogs, the procedure could not be completed (1 ventricular arrhythmia, 1 left atrial laceration, and 1 right ventricular outflow tract compression).

Conclusions. Endoscopic beating heart coronary artery bypass grafting is possible in a canine model using a computer-enhanced instrumentation system and articulating stabilization.     

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts.

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.     

The LAST operation is safe and effective: MIDCABG clinical and angiographic evaluation

BACKGROUND: The aim of this study was to prospectively evaluate the angiographic results of a cohort of consecutive patients who underwent minimally invasive coronary artery revascularization. METHODS: From May 1997 to December 1998, 150 consecutive patients underwent left internal mammary artery to left anterior descending artery anastomosis through a left minithoracotomy on a beating heart in the Cardiovascular Department of Cliniche Gavazzeni, Bergamo, Italy. The mean age was 61.6 years (range, 36 to 84 years); 121 patients (81%) were men. Isolated left anterior descending artery disease was present in 74 patients. RESULTS: In-hospital patency was observed in 100% of the 149 angiographically controlled patients with no anomalies in 99.3% of the anastomoses. Anastomosis was performed on a diseased tract of the target vessel in 3 patients and a stenosis of the target vessel beyond the anastomosis was documented in 3 patients. In one case early angiographic control was not performed due to death of the patient on the 1st postoperative day. The morbidity included postoperative bleeding that required reopening (3.3%) and intraoperative myocardial infarction (2%). CONCLUSIONS: A left internal mammary artery to left anterior descending artery anastomosis on a beating heart through a left minithoracotomy is an alternative approach to myocardial revascularization. Surgical invasiveness is limited, cardiopulmonary bypass risks are avoided, and the procedure is safe and effective. In our consecutive series, postoperative angiographic controls demonstrated graft patency in all patients and very high quality anastomoses. Midterm clinical follow-up (14 months) appears favorable.     

Complete arterial coronary revascularisation using radial artery conduit for double thoracic artery inlet flow: arterial sling operation.

BACKGROUND: Coronary artery bypass graft surgery with arterial revascularisation of all diseased coronary vessels is considered highly efficient because arterial grafts have an excellent long-term patency compared with venous grafts. However, problems to reach the infero-lateral wall with the in situ internal thoracic arteries usually require alternative techniques. We present the first results of a new surgical principle using a free radial artery segment to complete the arterial coronary revascularisation and concomitantly connect the internal thoracic arteries. METHODS: In patients referred for coronary bypass surgery and three-vessel disease an end-to-end anastomosis of the right internal thoracic artery and the radial artery segment preceded cardiopulmonary bypass, during which side-to-side anastomoses of the radial artery segment were used to revascularise stenotic branches of the right coronary and circumflex arteries. The left internal thoracic artery was used for revascularisation of stenotic branches of the left anterior descending artery, and finally an end-to-side anastomosis of the radial artery segment to the left internal thoracic artery was performed. Coronary artery blood flow was measured in 41 patients with Doppler flow probe. RESULTS: One hundred and ninety-two coronary anastomoses (an average of 4.2 per patient) were performed in 46 patients. We measured a mean total blood flow in the arterial sling graft of 104ml/min (range 35-221ml/min), compared with 69 and 68ml/min of the single inlet right and left internal thoracic arteries, respectively (P<0.01). Flow capacities of 104 and 120ml/min of the right and left internal thoracic arteries were measured during clamp of both the aorta and the contralateral internal thoracic artery. The mean crossclamp duration was 77min (range 51-113min). Postoperative angiography demonstrated patent graft anastomoses to all coronary arteries. There were no perioperative deaths or myocardial infarctions. One patient had a minor postoperative stroke. DISCUSSION: Complete arterial revascularisation can be achieved by the arterial sling operation with an acceptable crossclamp time and a high early rate of graft patency. The double arterial inlet provides a 50% higher blood flow to the beating heart and two-fold increase in the flow reserve compared with a single inlet. Although further research including long-term follow-up of this new principle is required, the present findings seem promising and suggest that the arterial sling operation has a potential role for complete arterial coronary revascularisation.