Composite Bilateral Internal Thoracic Artery Grafts via Standard Sternotomy for Lateral Wall Revascularization in Conscious Patients
DOI:
https://doi.org/10.1532/HSF98.20051164Abstract
Background. A new technique has been developed that permits complete arterial revascularization of the lateral wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, performed without cardiopulmonary bypass or mechanical ventilation, creates the least invasive revascularization method for the lateral wall of the heart yet described.
Methods. In 4 patients, double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started 1 hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique via standard median sternotomy. Circumflex branches were anastomosed with the left internal thoracic artery via a heart positioner.
Results. All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in only 1 patient and did not hinder the procedure. There were no hemodynamic changes during lateral wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses.
Conclusions. Complete arterial revascularization via median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach allows for complete coronary artery revascularization in patients with contraindications for general anesthesia with or without cardiopulmonary bypass.
References
Ngaage DL. 2003. Off-pump coronary bypass grafting: the myth, the logic and the science. Eur J Cardiothorac Surg 24:557-70.nGürbüz A, Kirali K, Tuncer A, Sismanoglu M, Yakut C. 2000. Combined transdiaphragmatic MIDCAB with right gastroepiploic artery and abdominal aortic aneurysm repair. Cardiovasc Surg 8:503-6.nÖmeroglu SN, Kirali K, Güler M, et al. 2000. Mid-term angiographic assessment of coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 70:844-9.nGersak B. 2003. A technique for aortic valve replacement on the beating heart with continuous retrograde coronary sinus perfusion with warm oxygenated blood. Ann Thorac Surg 76(4):1312-4.nVanek T, Straka Z, Brucek P, Widimsky P. 2001. Thoracic epidural anes thesia for off-pump coronary artery bypass without intubation. Eur J Cardiothorac Surg 20:858-60.nKirali K, Güler M, Daglar B, et al. 1999. Videothoracoscopic internalmammary artery harvest for coronary bypass. Asian Cardiovasc Thorac Ann 7:259-62.nLytle BW, Blackstone EH, Loop FD, et al. 1999. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 117:855-72.nMangano CTM. 2003. Risky business. J Thorac Cardiovasc Surg 125:1204-7.nBuffolo E, de Andrade JCS, Rodrigues Branco JNR, Teles CA, Aguiar LF, Gomes WJ. 1996. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 61:63-6.nKirali K, Daglar B, Güler M, et al. 1998. Videothoracoscopic LIMA harvesting and minimally invasive CABG procedure: a new technique in the coronary artery surgery. Turkish J Thorac Cardiovasc Surg 6:397-404.nHirose H, Amano A, Takahashi A. 2002. On-pump versus off-pump coronary artery bypass using quadruple arterial grafts. Asian Cardiovasc Thorac Ann 10:101-6.nPaiste J, Bjerke RJ, Williams JP, Zenati MA. 2001. Minimally invasive direct coronary artery bypass surgery under high thoracic epidural. Anesth Analg 93:1486-8.nBaumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Katouzian A, Yokoyama T. 1999. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 67:1653-8.nSchachner T, Bonatti J, Balogh D, et al. 2003. Aortic valve replacement in the conscious patient under regional anesthesia without endotracheal intubation. J Thorac Cardiovasc Surg 125:1526-7.nKaragöz H, Sönmez B, Bakkaloglu B, et al. 2000. Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia. Ann Thorac Surg 70:91-6.nIsik O, Daglar B, Kirali K, Balkanay M, Arbatli H, Yakut C. 1997. Coronary bypass surgery via minithoracotomy on the beating heart. Ann Tho-rac Surg 63(Suppl):S57-60.nKaragöz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. 2003. Coronary artery bypass grafting in the awake patient: three years' experience in 137 patients. J Thorac Cardiovasc Surg 125:1401-4.nBenetti FJ, Naselli C, Wood M, Geffner L. 1991. Direct myocardial revascularization without extracorporeal circulation. Experience in 700 patients. Chest 100:312-6.nAybek T, Kessler P, Khan MF, et al. 2003. Operative techniques in awake coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:1394-1400.nMariani MA, Gu YJ, Boonstra PW, Grandjean JG, van Oeveren W, Ebels T. 1999. Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate? Ann Thorac Surg 67:1370-5.nKirali K, Mansuroglu D, Kayalar N, Güzelmeric F, Alp M, Yakut C. 2003. Markers of myocardial ischemia in the evaluation of the effect of left anterior descending coronary artery lesion and collateral circulation on myocardial injury in 1-vessel off-pump coronary bypass surgery. Heart Surg Forum 6:143-8.nZenati MA, Paiste J, Williams JP, Strindberg G, Dumouchel JP, Griffith BP. 2001. Minimally invasive coronary bypass without general endotracheal anesthesia. Ann Thorac Surg 72:1380-2.nKirali K, Rabus MB, Yakut N, et al. 2002. Early- and long-term comparison of the on- and off-pump bypass surgery in patients with left ventricular dysfunction. Heart Surg Forum 5:177-81.nMansuroglu D, Sismanoglu M, Kirali K, Ömeroglu SN, Ipek D, Yakut C. 2004. A simple method to prevent internal thoracic artery from tension: single pericardio-thoracic suture technique [Review]. J Cardiac Surg 19:264-6.nGüler M, Kirali K, Toker ME, et al. 2001. The comparison of different CABG methods in patients with chronic obstructive pulmonary disease. Ann Thorac Surg 71:152-7.nHart JC. 2003. Maintaining hemodynamic stability and myocardial performance during off-pump coronary bypass surgery. Ann Thorac Surg 75:S740-4.n
