Hybrid coronary revascularization in high-risk patients

From January 2002 through June 2004, 17 patients (2% of all coronary cases) were treated with off-pump coronary artery bypass grafting combined with percutaneous coronary intervention. There were 13 men and 4 women, whose ages ranged from 54 to 78 years (mean, 63.1 +/- 20.9 yr). Preoperative angiography revealed 2-vessel coronary artery disease in 12 patients and 3-vessel disease in the remaining 5 patients. In all patients, extensive lesions (>50%) in the circumflex and right coronary arteries were treated first with a percutaneous intervention, followed by beating-heart coronary artery bypass grafting within 3 hours to treat the remaining obstructed vessels. Coronary angiography was performed 12 months after the operation to evaluate the effectiveness of the procedure. Procedure-related complications did not occur, and there was no in-hospital death. All patients underwent a successful left internal mammary artery-left anterior descending artery anastomosis with the exception of 1 patient, in whom we used a saphenous vein because of previous chest radiotherapy. The postoperative courses were uneventful, and no deterioration of preoperative organ dysfunction was noticed in any patient. There was no cardiac-related death or myocardial infarction. In follow-up angiography, all left internal mammary artery-left anterior descending artery anastomoses were patent. Three patients with restenosis were treated medically, which resulted in substantial reduction of angina. Hybrid coronary revascularization enables complete revascularization and may be an alternative method of treating selected patients who have concomitant disease.     

Hybrid coronary revascularization: a review

The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.     

Hybrid minimally invasive coronary artery revascularization

Background Hybrid coronary revascularization(HCR) is an alternative coronary revascularization strategy that combines a minimally invasive, survival advantage of the left internal mammary artery(LIMA)-left anterior descending(LAD) coronary artery bypass with less-invasive percutaneous coronary intervention(PCI)to non-LAD coronary lesions by using drug-eluting stents. We report our experience of hybrid minimally invasive approach in 15 patients. Methods From December 2012 to October 2013, 15 patients underwent revascularization of the left anterior descending artery through minimally invasive coronary artery bypass grafting(MIDCAB). All patients by endoscopic assist beating heart coronary artery bypass grafting. Seven patients were scheduled for a hybrid procedure. Percutaneous coronary intervention of non- LAD was performed 3 to 5 days preoperatively. Demographic data, perioperative outcome, and annual follow-up were obtained from all the patients. Results In-hospital mortality was 6.67%. The rate of conversion to full median sternotomy was 13.3%. Ventilation time was 6.9 ± 5.1 h. Blood loss volume was 241 ± 67.8 mL. ICU stay was21.3 ± 10.8 h. Hospital postoperative stay lasted for 7.5 ± 1.3 days. Prior to PCI patients showed 100% patent LIMA(Tables 3 and 4). A mean follow-up was 8.5 months. One year graft patency rate was 100%(8 / 8patients for 254-slice tomography). Two patients required reintervention. Conclusions Minimally invasive hybrid coronary revascularization is a safe, feasible and efficacious approach with good results and should be performed in selected patients by surgeons with experience in minimally invasive bypass surgery plus collaboration with cardiologists. eluting stents.     

"Hybrid" revascularization: video-thoracoscopy assisted MIDCAB combined with angioplasty

A "hybrid" revascularization technique has been developed for cases in which a chronic total occlusion of the left anterior descending coronary artery (LAD) cannot be recanalized by percutaneous coronary intervention, but the lesions in the right coronary artery and/or left circumflex artery are very good candidates for angioplasty. This technique, which uses video-thoracoscopy assisted minimally invasive direct coronary artery bypass to recanalize the occluded LAD and angioplasty to dilate favorable lesions in other vessels, would achieve complete revascularization in selected patients with multi-vessel disease. In this preliminary study of four patients, angioplasty and stenting were successful in all patients without any complications; complete revascularization was achieved in all 4 patients. No recurrence of angina and no cardiovascular events developed during follow-up; this study therefore supports the belief that the "hybrid" revascularization technique is both feasible and safe.     

Hybrid coronary revascularization for the treatment of left main coronary stenosis: a feasibility study

Objective : To determine the feasibility of a hybrid coronary revascularization (HCR) approach for the treatment of left main (LM) coronary artery stenosis. Background : The recommended therapy for significant LM stenosis is coronary artery bypass grafting (CABG). Percutaneous coronary intervention (PCI) of unprotected LM lesions is reserved for patients at high risk for complications with CABG. HCR in LM disease has not been studied. Methods : Twenty‐two consecutive patients with LM stenosis >70% underwent staged HCR. Following a robotic or thoracoscopic‐assisted minimally invasive left internal mammary artery (LIMA) to left anterior descending artery (LAD) coronary bypass, PCI of the LM, and non‐LAD targets was performed after angiographic confirmation of LIMA patency. Intravascular ultrasound confirmed optimal stent deployment. Thirty‐day adverse outcomes and long term follow up was obtained. Results : In the 22 patients with LM lesions, 6 were ostial, 5 mid, and 11 distal. LIMA patency was FitzGibbon A in all cases. LM stenting was successful in all patients with drug‐eluting stents (DES) placed in 21 of 22 cases. Three patients underwent stent implantation in the right coronary artery. There were no 30‐day major adverse cardiac or cerebrovascular events. At a mean of 38.8 ± 22 months postprocedure, 21 patients were alive without reintervention; one death occurred at 454 days. Conclusions : HCR for LM coronary disease is a feasible alternative to CABG and unprotected LM PCI. This approach combines the long‐term durability of a LIMA‐LAD bypass with the less invasive option of PCI in non‐LAD targets with DES. © 2011 Wiley Periodicals, Inc.     

Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease

OBJECTIVEHybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease.METHODSThis cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years.RESULTSThere was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67−1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34−0.77)). CONCLUSIONSFor patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.

For most patients with multivessel disease coronary artery disease, either coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) is the recommended option. The advantage of CABG surgery is generally the durability of the bypass grafts, and CABG surgery is recommended especially among the highest risk patients (e.g., three vessel disease, left main (LM) disease, multivessel disease with proximal left anterior descending artery (LAD) disease).^[1-4] Nevertheless, an advantage of CABG surgery is the superior outcomes achieved with left internal mammary artery (LIMA) grafts to the LAD for patients with LAD disease.^[5-7]Hybrid coronary revascularization (HCR) is an approach that has been developed to combine the main advantages of both CABG surgery and PCI. It consists of using a LIMA anastomosis to the LAD via a minimally invasive CABG surgery approach (no sternotomy) in addition to PCI for other diseased coronary arteries. The rationale for using this approach in lieu of using PCI for all diseased coronary arteries is the potential for more durability of the LAD revascularization as a result of the LIMA to LAD anastomosis. Several studies have compared HCR to CABG surgery, but they are limited with respect to sample size, number of institutions represented, duration, and inability to capture population-based practice.^[8-24] Multi-center studies comparing HCR with PCI, which are arguably more relevant since these two alternatives are the least invasive ones, are extremely limited.^[25,26]The purposes of this study are to: (1) describe the use of HCR and the characteristics of patients undergoing HCR vs. PCI in a population-based setting, and (2) compare short- and medium-term outcomes for HCR and PCI for patients with multi-vessel coronary artery disease accompanied by LAD disease using New York’s clinical cardiac registries.     

Hybrid revascularization using percutaneous coronary intervention and robotically assisted minimally invasive direct coronary artery bypass surgery

Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-left anterior descending (LAD) territories with minimally invasive direct coronary artery bypass (MIDCAB) using the left internal thoracic artery (LITA) to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to perform full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages associated with the percutaneous treatment of symptomatic coronary stenoses. We investigated whether HR was a valid alternative to conventional coronary artery bypass graft surgery in patients with multivessel coronary artery disease. We also present our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.     

Hybrid thoracoabdominal aneurysm repair with simultaneous antegrade visceral revascularization and supra-aortic debranching from the ascending aorta.

PURPOSE: To describe a hybrid technique involving combined antegrade revascularization of both supra-aortic and visceral arteries and complete exclusion of a dissecting thoracoabdominal aortic aneurysm (TAAA). TECHNIQUE: A 46-year-old man had a dissecting TAAA involving the left subclavian artery (LSA) and the descending thoracic and abdominal aorta down to the left common iliac artery. The ascending aorta was the only feasible source of inflow to the cerebral and visceral vessels. Via a median thoracolaparotomy, the supra-aortic and visceral arteries were dissected, and an octopus graft was implanted using 3 bifurcated Dacron grafts. An 18-x9-mm bifurcated Dacron graft was anastomosed in an end-to-side fashion to the ascending aorta, the brachiocephalic trunk, and the left common carotid artery. A 16-x8-mm bifurcated Dacron graft was sutured end-to-side to the celiac artery and superior mesenteric artery. A third 12-x7-mm bifurcated graft was sutured to both renal arteries. In a second step, 3 tapered custom-made thoracic Zenith TX2 endografts were used to repair the thoracic and the thoracoabdominal aorta. A bifurcated Zenith AAA device was used to treat the aneurysm at the level of the infrarenal aorta and both iliac arteries. Despite covering the LSA and all intercostal and lumbar arteries, the patient developed only a temporary paresis of the left leg. Computed tomography showed complete exclusion of the aneurysm and normal flow to the supra-aortic and visceral arteries. CONCLUSION: In selected cases, this hybrid approach using the ascending aorta for antegrade revascularization of cerebral and visceral arteries is feasible, with acceptable perioperative morbidity. However, its role for the treatment of complex thoracoabdominal aortic disease must be evaluated further.     

Transmyocardial laser revascularization

Low-powered lasers were first used in the early 1980s to produce transventricular channels as an adjunct to coronary artery bypass graft surgery (CABG). Early results were encouraging, but because of the combined procedure, could not be attributed directly to use of the laser [1]. High-powered lasers were introduced into clinical practice in 1990 [2]. These lasers are powerful enough to create a transmyocardial channel with minimal thermal damage to surrounding tissues [3]. Clinical studies, using transmyocardial laser revascularization (TMR) as the sole operative therapy for patients with severe and diffuse coronary artery disease (CAD) who have Class III or IV angina, and are on medical therapy, have been conducted since 1993. Based on the results of these studies, the FDA granted approval for the use of TMR as a sole therapy. Clinical studies are currently underway to assess the results of combined TMR and CABG [4]. Results of four controlled randomized studies have been published [5-8]. The data from two of these studies formed the basis for FDA approval of two different types of laser systems. The results of these studies have not provided any additional insights into the mechanism of action of TMR, which remains the Achilles' heel of this procedure. In this review, background information about the TMR procedure will be discussed along with an analysis of the recently published randomized studies.     

Nonsurgical carotid revascularization

Carotid endarterectomy is a well-established treatment of improving the carotid luminal diameter and preventing strokes, and the indications and complications are well-defined. Carotid angioplasty and stent placements are relatively newer ways of treating carotid artery stenosis. In certain contexts, they may have some advantages over carotid endarterectomy. However, the success rates, morbidity, and mortality associated with these procedures are less well characterized. In earlier comparative studies, the incidence of ipsilateral stroke rate was higher with angioplasty, but in later studies, this trend is reversing. Angioplasty may also have an edge in specific situations like patients with coexisting significant coronary arterial disease, contralateral carotid artery occlusion, and in instances when the narrowing is long and at multiple sites. Protective devices like distal occlusion balloon and filter protection devices may reduce the incidence of stroke. We are still awaiting the results of some major randomized head-to-head trials comparing carotid endarterectomy and stenting.     

Late renal revascularization

Late renal revascularization could be indicated in totally occluded renal artery with hypertension and or renal insufficiency. Six cases of secondary revascularization after occlusion of renal artery are reported here. In three cases severe renovascular hypertension was the indication for renal revascularization. In three other cases, indication was proposed for renal insufficiency. In four cases, renal revascularization for totally occluded renal artery have been beneficial for the patients. In two cases of terminal renal insufficiency, chronical hemodialysis could be suppressed. In the others two cases, hypertension was clearly improved. The criteria for renal revascularization before and during surgery are discussed here. The kidney length, the cortico-medullary ratio at kidney echography, and the visualization of a nephrography during angiography are the principal criteria before surgery for renal revascularization. The macroscopic aspect of the kidney, the immediate results of renal biopsy and the importance of a blood reflow in the renal artery are the principal criteria during surgery, but must be discussed because there are no definitive criteria. Renal revascularization shall be proposed when totally occluded renal artery is associated with renal insufficiency and/or hypertension, especially when the other side can be affected by the same disease.     

激光心肌血运重建术

经皮冠状动脉腔内成形术(ＰＴＣＡ)和冠状动脉旁路移植术(ＣＡＢＧ)已经大大改善了复杂冠心病患者的长期预后。然而,药物治疗无效,且不适宜ＰＴＣＡ和ＣＡＢＧ治疗的严重心绞痛患者日益增多,成为临床治疗中的难题。近年来,激光心肌血运重建术(ＴＭＲ)和经皮激光血运重建术(ＰＭＲ)已用于临床,随机临床试验已经获得了可喜的结果,为这些病人提供了一种新的治疗方法。1　适应证和禁忌证　　理论上讲ＴＭＲ和ＰＭＲ适应于各种类型的缺血性心脏病,但经临床实践,我们认为主要适用于以下情况:(1)严重心绞痛[加拿大心血管学会分级(ＣＣＳ)3～4级],药…     

Transmyocardial laser revascularization

Opinion statement Transmyocardial laser revascularization (TMR) has been performed on over 12,000 patients worldwide. Since 1990, the treatment has provided significant angina relief for symptomatic end-stage coronary disease that is refractory to medical therapy. Seventy-five percent of patients treated with TMR have demonstrated a decrease of two or more angina classes postoperatively. As a result, TMR has provided a significant improvement in quality of life for patients, resulting in fewer hospital admissions and decreased dependency on medications. Two different wavelengths of light, carbon dioxide (CO₂) and holmium yttrium-aluminum-garnet (Ho:YAG), have been employed. Results obtained using these lasers differ. The CO₂ laser has demonstrated a perfusion benefit as well as long-term improvement in quality of life and angina relief. The Ho:YAG laser has not demonstrated these results. These differences may, in part, explain the failure of percutaneous myocardial laser revascularization. This catheterbased approach was not as successful as TMR due to its partial thickness treatment of the myocardium as well as its use of the Ho:YAG laser. In addition to the patients with end-stage coronary disease who undergo TMR as sole therapy, there are an increasing number of patients who have been treated with a combination of coronary artery bypass grafting and TMR. This provides a more complete revascularization than leaving territories ungrafted. Further enhancement of the angiogenic response seen after TMR may be seen by the addition of gene therapy to TMR treatment.