Download Surgical Treatment of Coronary Artery Disease

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6
Surgical Treatment of
Coronary Artery Disease
William E. Cohn, O.H. Frazier, and
Denton A. Cooley
Standard Coronary Artery Bypass Grafting . . . . . . . . . 1052
Cardiopulmonary Bypass . . . . . . . . . . . . . . . . . . . . . . . . 1060
Off-Pump Coronary Artery Bypass . . . . . . . . . . . . . . . . 1061
Key Points
• Techniques and technology for treating coronary artery
disease (CAD) have evolved significantly over the past
40 years.
• Although there are cases in which the best treatment
approach (medical, surgical, or catheter-based) is clear,
the best choice of intervention is not obvious for the
majority of patients.
• Five, 7, and 10 years after initial treatment, mortality is
lower for coronary artery bypass grafting (CABG) than
for medical treatment alone. These survival benefits of
CABG are particularly substantial for patients with
three-vessel or left main artery disease, severe angina, or
a positive pretreatment exercise stress test.
• Most trials comparing CABG with catheter-based
interventions (CBIs) in patients with multivessel disease
have shown similar short-term survival benefits for both
treatments, but CBIs have been associated with less
periprocedural morbidity and CABG with longer-lasting
revascularization.
• Substantial evidence suggests that CABG is preferable to
CBI in certain types of patients, including the one third
of CAD patients who have chronic total occlusion of one
or more vessels, and those with diabetes mellitus.
• Meta-analyses of large numbers of CABG studies report
30-day mortality rates in the 1% to 2% range.
• Numerous CABG techniques have evolved that seem to
produce equally good results.
• Substantial evidence suggests that internal mammary
artery grafts more effectively promote short- and longterm survival than do saphenous vein grafts, especially
when used to graft the left anterior descending (LAD)
coronary artery. In fact, the bulk of the evidence suggests
that CABG with left internal mammary artery (LIMA)to-LAD grafting provides better long-term results than
does either CABG with other types of conduits or CBI.
• Technical innovations made in the attempt to reduce the
negative impact of cardiopulmonary bypass (CPB) include
Reducing the Invasiveness of Coronary
Artery Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1068
coating the internal surface with heparin or other polymers to reduce contact between blood and the CPB mechanism, minimizing hemodilution by shrinking the
bypass circuit to reduce the amount of crystalloid prime
needed to start CPB, and using hemofiltration to protect
the heart and end organs.
• Current United States estimates (based on industry
reports) suggest that 18% to 25% of the 370,000 annual
CABG procedures are performed without the use of CPB.
• There is not yet complete agreement about the relative
safety and efficacy of off-pump coronary artery bypass
(OPCAB) and conventional CABG with CPB.
• The difficulty in comparing the OPCAB and standard
CABG stems in part from the low incidences of
mortality and significant morbidity associated with both
techniques.
• A meta-analysis of 37 randomized, controlled trials of
OPCAB suggests that it is associated with significantly
decreased transfusion and inotrope requirements, atrial
fibrillation, respiratory infections, ventilation time, intensive care unit stay, hospital stay, and overall in-hospital
and (1-year) postdischarge costs compared with standard
CABG.
• Data from many large nonrandomized studies suggest
that OPCAB is associated with a lower incidence of death,
stroke, intraaortic balloon pump requirement, and
postoperative transfusion, and a shorter average time
on ventilator and length of hospital stay compared with
conventional CABG. However, selection bias cannot be
ruled out as a potential confounding variable in these
data.
• Devices and techniques for lateral and inferior wall exposure have enabled surgeons performing OPCAB to attach
grafts to all aspects of the heart. Recent series show no
difference in the average number of grafts constructed in
OPCAB and standard CABG, and several series have
shown excellent graft patency.
• Off-pump bypass is ideal for patients with significant
atheroma or calcification of the ascending aorta.
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• A few studies have shown that OPCAB is associated with
a reduced incidence of neurocognitive dysfunction compared with conventional CABG with CPB, but other
studies have shown no significant differences.
• Results of small randomized trials suggest that, in
patients with stenosis of the proximal LAD, minimally
invasive direct coronary artery bypass (MIDCAB) is
associated with a longer in-hospital recovery period and
higher costs than is direct stenting, but that MIDCAB
produces similar or better short- and long-term
outcomes.
• Totally videoscopic LIMA-to-LAD procedures have been
performed in which surgical robots were used to mobilize
the LIMA and make the sutured anastomosis, but robots
are not likely to be in widespread use for CABG in the
near future because of their expense and the challenges
involved in learning to use them.
• Although port-access CPB has been used successfully in
multivessel CABG performed through small fifth intercostal space thoracotomies, this procedure has fallen out
of favor, partly because of the difficulty of constructing
grafts of appropriate length and lie.
Coronary artery bypass grafting (CABG) remains the primary
invasive treatment for coronary artery occlusive disease, particularly in patients for whom catheter-based intervention
(CBI) is not appropriate. It is estimated that 515,000 CABG
procedures were performed in the United States in 2002.1
The answer to the question of who performed the fi rst
successful CABG operation depends largely on one’s criteria
for success. The most commonly accepted notion is that it
was Sabiston,2 who in 1962 performed a bypass to the right
coronary artery without using extracorporeal circulation.
However, the patient died of a stroke 3 days after the operation; a blood clot was found at the origin of the graft in the
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aorta. Therefore, some argue that the first successful CABG
procedure was performed in 1964 by Garrett,3 who, while
performing an endarterectomy, encountered technical difficulties and was forced to bypass the left anterior descending
(LAD) artery. This patient was still alive 7 years later.4 In any
event, much of the pioneering work that followed was done
by Favaloro,5 who popularized the use of autogenous saphenous vein grafts; by Kolesov, who performed the first
mammary artery-to-coronary anastomosis in 1964;6 and
later by Effler7 at the Cleveland Clinic and by Johnson and
Lepley8 in Milwaukee.
Since those first operations, CABG techniques and
technology have evolved significantly. This chapter describes
the various options available to surgeons performing CABG
procedures and the evidence that supports the use of each
approach in particular situations.
Standard Coronary Artery Bypass
Grafting
Indications
The major indications for coronary revascularization remain
myocardial ischemia and disabling angina pectoris. It may
also be performed as a concomitant procedure in patients
with cardiac failure resulting from ventricular aneurysm,
ventricular septal perforation, papillary muscle rupture, or
valvular disease. Although there are cases in which the best
treatment approach (medical, surgical, or catheter-based) is
clear, and although the American Heart Association’s guidelines (Table 46.1) are often helpful in treatment selection, the
best choice of intervention is not obvious for the majority of
patients.
TABLE 46.1. American Heart Association guidelines regarding indications for coronary artery bypass grafting (CABG) surgery
9.2.1 Asymptomatic or Mild Angina
Class I
1. CABG should be performed in patients with asymptomatic or mild angina who have significant left main coronary artery stenosis.
(Level of evidence: A)
2. CABG should be performed in patients with asymptomatic or mild angina who have left main equivalent: significant (greater than or
equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: A)
3. CABG is useful in patients with asymptomatic ischemia or mild angina who have three-vessel disease. [Survival benefit is greater in
patients with abnormal left ventricle (LV) function; e.g., left ventricular ejection fraction (LVEF) less than 0.50 and/or large areas of
demonstrable myocardial ischemia.] (Level of evidence: C)
Class IIa
CABG can be beneficial for patients with asymptomatic or mild angina who have proximal LAD stenosis with one- or two-vessel disease.
(This recommendation becomes a class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.)
(Level of evidence: A)
Class IIb
CABG may be considered for patients with asymptomatic or mild angina who have one- or two-vessel disease not involving the proximal
LAD. (If a large area of viable myocardium and high-risk criteria are met on noninvasive testing, this recommendation becomes class I).
(Level of evidence: B)
9.2.2 Stable Angina
Class I
1. CABG is recommended for patients with stable angina who have significant left main coronary artery stenosis. (Level of evidence: A)
2. CABG is recommended for patients with stable angina who have left main equivalent: significant (≥70%) stenosis of the proximal LAD
and proximal left circumflex artery. (Level of evidence: A)
3. CABG is recommended for patients with stable angina who have three-vessel disease. (Survival benefit is greater when LVEF is less
than 0.50.) (Level of evidence: A)
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TABLE 46.1. (continued)
4. CABG is recommended in patients with stable angina who have two-vessel disease with significant proximal LAD stenosis and either
EF less than 0.50 or demonstrable ischemia on noninvasive testing. (Level of evidence: A)
5. CABG is beneficial for patients with stable angina who have one- or two-vessel CAD without significant proximal LAD stenosis but
with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Level of evidence: B)
6. CABG is beneficial for patients with stable angina who have developed disabling angina despite maximal noninvasive therapy, when
surgery can be performed with acceptable risk. If angina is not typical, objective evidence of ischemia should be obtained. (Level of
evidence: B)
Class IIa
1. CABG is reasonable in patients with stable angina who have proximal LAD stenosis with one-vessel disease. (This recommendation
becomes class I if extensive ischemia is documented by noninvasive study and/or LVEF is less than 0.50.) (Level of evidence: A)
2. CABG may be useful for patients with stable angina who have one- or two-vessel CAD without significant proximal LAD stenosis but
who have a moderate area of viable myocardium and demonstrable ischemia on noninvasive testing. (Level of evidence: B)
Class III
1. CABG is not recommended for patients with stable angina who have one- or two-vessel disease not involving significant proximal
LAD stenosis, patients who have mild symptoms that are unlikely due to myocardial ischemia, or patients who have not received an
adequate trial of medical therapy and:
a. have only a small area of viable myocardium. (Level of evidence: B)
b. have no demonstrable ischemia on noninvasive testing. (Level of evidence: B)
2. CABG is not recommended for patients with stable angina who have borderline coronary stenosis (50% to 60% diameter in locations
other than the left main coronary artery) and no demonstrable ischemia on noninvasive testing. (Level of evidence: B)
3. CABG is not recommended for patients with stable angina who have insignificant coronary stenosis (less than 50% diameter
reduction). (Level of evidence: B)
9.2.3 Unstable Angina/Non–ST-Segment Elevation MI (NSTEMI)
Class I
1. CABG should be performed for patients with unstable angina/NSTEMI with significant left main coronary artery stenosis. (Level of
evidence: A)
2. CABG should be performed for patients with unstable angina/NSTEMI who have left main equivalent: significant (greater than or
equal to 70%) stenosis of the proximal LAD and proximal left circumflex artery. (Level of evidence: A)
3. CABG is recommended for unstable angina/NSTEMI in patients in whom revascularization is not optimal or possible, and who have
ongoing ischemia not responsive to maximal nonsurgical therapy. (Level of evidence: B)
Class IIa
CABG is probably indicated for patients with unstable angina/NSTEMI who have proximal LAD stenosis with one- or two-vessel disease.
(Level of evidence: A)
Class IIb
CABG may be considered in patients with unstable angina/NSTEMI who have one- or two-vessel disease not involving the proximal
LAD when percutaneous revascularization is not optimal or possible. (If there is a large area of viable myocardium and high-risk
criteria are met on noninvasive testing, this recommendation becomes Class I.) (Level of evidence: B)
9.2.4 ST-Segment Elevation MI (STEMI)
Class I
Emergency or urgent CABG in patients with STEMI should be undertaken in the following circumstances:
a. Failed angioplasty with persistent pain or hemodynamic instability in patients with coronary anatomy suitable for surgery. (Level of
evidence: B)
b. Persistent or recurrent ischemia refractory to medical therapy in patients who have coronary anatomy suitable for surgery, who have a
significant area of myocardium at risk, and who are not candidates for PCI. (Level of evidence: B)
c. At the time of surgical repair of postinfarction ventricular septal rupture or mitral valve insufficiency. (Level of evidence: B)
d. Cardiogenic shock in patients less than 75 years old with ST-segment elevation or left bundle branch block or posterior MI who
develop shock within 36 hours of MI and are suitable for revascularization that can be performed within 18 hours of shock, unless
further support is futile because of patient’s wishes or contraindications/unsuitability for further invasive care. (Level of evidence: A)
e. Life-threatening ventricular arrhythmias in the presence of ≥50% left main stenosis and/or triple-vessel disease. (Level of evidence: B)
Class IIa
1. CABG may be performed as primary reperfusion in patients who have suitable anatomy and who are not candidates for or who have
had failed fibrinolysis/percutaneous coronary intervention (PCI) and who are in the early hours (6 to 12 hours) of evolving STEMI.
(Level of evidence: B)
2. In patients who have had an STEMI or NSTEMI, coronary artery bypass graft (CABG) mortality is elevated for the fi rst 3 to 7 days
after infarction, and the benefit of revascularization must be balanced against this increased risk. Beyond 7 days after infarction, the
criteria for revascularization described in previous sections are applicable. (Level of evidence: B)
Class III
1. Emergency CABG should not be performed in patients with persistent angina and a small area of myocardium at risk who are
hemodynamically stable. (Level of evidence: C)
2. Emergency CABG should not be performed in patients with successful epicardial reperfusion but unsuccessful microvascular
reperfusion. (Level of evidence: C)
(Continued)
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TABLE 46.1. (continued)
9.2.5 Poor LV Function
Class I
1. CABG should be performed in patients with poor LV function who have significant left main coronary artery stenosis. (Level of
evidence: B)
2. CABG should be performed in patients with poor LV function who have left main equivalent: significant (≥70%) stenosis of the
proximal LAD and proximal left circumflex artery. (Level of evidence: B)
3. CABG should be performed in patients with poor LV function who have proximal LAD stenosis with two- or three-vessel disease.
(Level of evidence: B)
Class IIa
CABG may be performed in patients with poor LV function with significant viable noncontracting, revascularizable myocardium and
without any of the above anatomic patterns. (Level of evidence: B)
Class III
CABG should not be performed in patients with poor LV function without evidence of intermittent ischemia and without evidence of
significant revascularizable viable myocardium. (Level of evidence: B)
9.2.6 Life-Threatening Ventricular Arrhythmias
Class I
1. CABG should be performed in patients with life-threatening ventricular arrhythmias caused by left main coronary artery stenosis.
(Level of evidence: B)
2. CABG should be performed in patients with life-threatening ventricular arrhythmias caused by three-vessel coronary disease. (Level of
evidence: B)
Class IIa
1. CABG is reasonable in bypassable one- or two-vessel disease causing life-threatening ventricular arrhythmias. (This becomes a class I
recommendation if the arrhythmia is resuscitated sudden cardiac death or sustained ventricular tachycardia.) (Level of evidence: B)
2. CABG is reasonable in life-threatening ventricular arrhythmias caused by proximal LAD disease with one- or two-vessel disease.
(This becomes a class I recommendation if the arrhythmia is resuscitated sudden cardiac death or sustained ventricular tachycardia.)
(Level of evidence: B)
Class III
CABG is not recommended in ventricular tachycardia with scar and no evidence of ischemia. (Level of evidence: B)
9.2.7 CABG After Failed Percutaneous Transluminal Coronary Angioplasty (PTCA)
Class I
1. CABG should be performed after failed PTCA in the presence of ongoing ischemia or threatened occlusion with significant
myocardium at risk. (Level of evidence: B)
2. CABG should be performed after failed PTCA for hemodynamic compromise. (Level of evidence: B)
Class IIa
1. It is reasonable to perform CABG after failed PTCA for a foreign body in crucial anatomic position. (Level of evidence: C)
2. CABG can be beneficial after failed PTCA for hemodynamic compromise in patients with impairment of the coagulation system and
without previous sternotomy. (Level of evidence: C)
Class IIb
CABG can be considered after failed PTCA for hemodynamic compromise in patients with impairment of the coagulation system and
with previous sternotomy. (Level of evidence: C)
Class III
1. CABG is not recommended after failed PTCA in the absence of ischemia. (Level of evidence: C)
2. CABG is not recommended after failed PTCA with inability to revascularize due to target anatomy or no-reflow state. (Level of
evidence: C)
9.2.8 Patients with Previous CABG
Class I
1. Coronary bypass should be performed in patients with prior CABG for disabling angina despite optimal nonsurgical therapy. (If angina
is not typical, then objective evidence of ischemia should be obtained.) (Level of evidence: B)
2. Coronary bypass should be performed in patients with prior CABG without patent bypass grafts but with class I indications for
surgery for native-vessel CAD (significant left main coronary stenosis, left main equivalent, three-vessel disease). (Level of evidence: B)
Class IIa
1. Coronary bypass is reasonable in patients with prior CABG and bypassable distal vessel(s) with a large area of threatened myocardium
by noninvasive studies. (Level of evidence: B)
2. Coronary bypass is reasonable in patients who have prior CABG if atherosclerotic vein grafts with stenoses greater than 50%
supplying the LAD coronary artery or large areas of myocardium are present. (Level of evidence: B)
LAD, left anterior descending; CABG, coronary artery bypass grafting; LV, left ventricle; LVEF, left ventricular ejection fraction; CAD, coronary artery disease;
MI, myocardial infarction; PCI, percutaneous coronary intervention; PCTA, percutaneous transluminal angioplasty.
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Comparing Coronary Artery Bypass
Grafting and Medical Treatment
Stenting
96
CABG
94
92
p = .75
0
A
0
60
120
180
240
300
360
100
Comparing Coronary Artery Bypass Grafting
and Catheter-Based Interventions
98
96
94
CABG
92
Stenting
p = .71
90
0
B
0
60
120
180
240
300
360
100
Event-free survival (%)
In the treatment of coronary artery disease, CBIs have the
advantage of being minimally invasive, thereby promoting
faster recovery and earlier hospital discharge than is usual
with standard CABG surgery. For this reason, coronary CBIs
are now performed twice as often as CABG surgery in the
U.S. Nonetheless, CABG has advantages that have kept this
procedure in use.
Reviews of trials comparing CABG with CBI in patients
with multivessel disease have found that, in most trials,
CABG and CBI show similar short-term survival benefits,
but CBI is associated with less periprocedural morbidity.10,11
However, CABG tends to produce longer-lasting revascularization. In the Medicine, Angioplasty, or Surgery Study
(MASS II) trial, in which 611 CAD patients were randomly
assigned to medical therapy, multivessel CBI, or CABG, 8.3%
of the medical group and 13.3% of the CBI group required
repeat revascularization within a year of treatment, compared with 0.5% of the CABG patients (Fig. 46.1).12 Similarly,
98
90
Event-free survival (%)
It has been known for some time that CABG produces better
outcomes than does medical treatment alone for patients
with significant coronary artery disease (CAD). A metaanalysis of follow-up data from randomized trials performed
in the 1970s and 1980s, including the Veterans Administration Cooperative Trial, the Coronary Artery Surgery Study
(CASS), and the European Coronary Surgery Study, found that
mortality is lower for CABG than for medical treatment
alone 5 years (10.2% vs. 15.8%), 7 years (15.8% vs. 21.7%), and
10 years (26.4% vs. 30.5%) after initial treatment.9 The survival benefits of CABG were particularly substantial for
patients with three-vessel or left main artery disease, more
severe angina, or a positive pretreatment exercise stress test.
Survival (%)
100
95
CABG
90
85
80
75
Stenting
p < .001
70
0
0
60
120
180
240
300
360
C
Days since randomization
FIGURE 46.2. Patients in the ARTS trial who underwent coronary artery bypass grafting (CABG) or catheter-based intervention
(CBI) with stenting had similar outcomes when actuarial survival
(A) and survival without myocardial infarction or cerebrovascular
events (B) were considered. However, when repeat revascularization was combined with these other end points (C), outcomes
were better in CABG patients.
1.00
Freedom from additional PCI
CABG
MT
0.95
PCI
0.90
0.85
0.80
p = .0001
0
2
4
6
8
Months after study entry
10
12
FIGURE 46.1. Freedom from additional revascularization among
coronary artery disease (CAD) patients in the MASS-II trial who
received medical treatment only (MT), coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI).
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the randomized, 1000-patient Arterial Revascularization
Therapies Study Group (ARTS) trial showed 1-year repeatrevascularization rates of 16.8% in CBI patients and 3.1% in
CABG patients (Fig. 46.2).13 Finally, in the Stent or Surgery
(SoS) trial, in which 1000 CAD patients at 53 centers were
randomly assigned to multivessel stenting or CABG, 21% of
the CBI patients required additional revascularization at a
median follow-up of 2 years, compared with only 6% of the
CABG patients (Fig. 46.3).14
Substantial evidence suggests that CABG is preferable to
CBI in certain types of patients. For example, one third of
CAD patients who require more than medical therapy alone
have chronic total occlusion of one or more vessels.15 Two
trials of CABG and CBI that included patients with totally
occluded vessels have shown that CBI does not produce adequate revascularization in these vessels. In the Randomized
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Cumulative proportion
at risk (%)
30
Hazard ratio 3.85
(95% CI 2.56−5.79),p <.0001
25
PCI
20
15
10
CABG
5
0
0
1
2
Time since randomization (years)
3
Numbers at risk
PCI
488
393
228
64
CABG
500
478
281
83
FIGURE 46.3. In the SoS trial, risk of repeat revascularization was
considerably greater in CAD patients who underwent percutaneous
coronary intervention (PCI) than in those who underwent coronary
artery bypass grafting (CABG).
46
Intervention Treatment of Angina (RITA) trial,16 only 48%
of attempts to revascularize totally occluded arteries with
CBI were considered successful (i.e., reduced stenosis to 50%
or less). In the Coronary Angioplasty versus Bypass Revascularization Investigation (CABRI) trial,17 only 70% of occluded
arteries were successfully revascularized with CBI.
There are other subgroups of CAD patients that may also
benefit more from CABG than from CBI. For example, in
patients with left main artery disease, this vessel may be
particularly vulnerable to restenosis after CBI.18 Additionally, CAD patients with diabetes mellitus have better 5-year
survival after CABG with internal mammary artery (IMA)
grafts than after CBI.19
Coronary Artery Bypass Grafting Techniques
The technology used in CABG surgery has evolved substantially over the past three decades. Refinements in operative
technique (Figs. 46.4 to 46.8) have continued to improve
outcomes in a patient population that is increasingly infirm.
Meta-analyses of large numbers of CABG studies report 30day mortality rates in the 1% to 2% range.20,21
It is interesting to note that numerous CABG techniques
have evolved that seem to produce equally good results. Some
FIGURE 46.4. Surgical anatomy of the coronary
system. (A) The right coronary system has several
branches that can be considered for bypass. In
some instances, the acute marginal branch (AM)
is bypassed, particularly if it has a large retrograde
collateral blood supply to the left system. Most
anastomoses are made at the area of the crux. The
posterior ventricular branch (PVB), posterior
descending branches (PD), or their distal branches
may be grafted. The dotted line indicates the area
of the interventricular septum as denoted by the
right coronary vein. RCA, right coronary artery.
(B) In the left anterior descending coronary artery
(LAD) system, the fi rst septal perforator (1st SPL)
is usually just opposite the fi rst diagonal (1st DX)
branch or is proximal to it. It descends posteriorly
into the interventricular septum and may be an
important artery. The 1st DX and second diagonal
(2nd DX) branches arise from the LAD. The distal
LAD usually supplies the apex of the left ventricle. The ramus medialis branch (RM) arises
between the circumflex (CX) and the LAD and
may be in the DX or obtuse marginal position. (C)
The CX coronary system shows the fi rst branch
as the fi rst obtuse marginal (1st OM) and the
second branch as the second obtuse marginal (2nd
OM) or posterior lateral branch (PLB) of the CX
system. The main CX trunk is in the atrioventricular groove in close association with the coronary sinus vein.
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FIGURE 46.5. Saphenous vein graft to
the right coronary artery. (A) The right
coronary artery is isolated by placing a
traction suture in the myocardium
beneath the right coronary artery. (Inset)
The vein is beveled, depending on the
length of the anastomosis and the size of
the vein. (B) The coronary artery is
incised, and the incision is extended with
the use of Potts scissors. (C) The right
coronary anastomosis is begun at the
distal portion of the artery and the toe of
the vein graft. (D) The anastomosis is
sutured on the right side fi rst, from the
artery to the vein. (E) The anastomosis is
completed from the left side. The suture
is usually tied at or to the right of the
apex. (F) The proximal anastomosis is
completed with the aid of either complete
or partial aortic occlusion. (G) The clamp
is removed, and air is evacuated from the
vein graft. The vein graft may be clamped
with a small bulldog clamp to avoid
introducing more air into the coronary
system.
centers perform only the distal anastomoses while the heart
is arrested and perform the proximals with a side-biting
clamp and bypass, whereas other centers keep the heart
arrested while all grafts are performed. Cardioplegia techniques vary widely among surgeons and institutions in terms
of the use of warm blood, cold blood, or crystalloid, the
number and timing of doses, and the route by which doses
are given (anterograde or retrograde), but there is not widespread agreement about which of these methods is best.
One area of bypass surgery in which the evidence does
favor particular options is choice of conduit. Saphenous
vein harvest has become more sophisticated and less invasive over the past several years, producing venous segments
of similar quality to those harvested with open techniques
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while causing fewer complications.22–24 However, there is
plenty of evidence to suggest that IMA grafts (Fig. 46.9)
more effectively promote short- and long-term survival
than do saphenous vein grafts, especially when used to
graft the LAD (Fig. 46.10).25–28 Additionally, a long-term
study has shown that left IMA (LIMA)-to-LAD grafts have
an 88% patency rate 15 years after surgery (Fig. 46.11).29 In
fact, the bulk of the evidence suggests that CABG with
LIMA-to-LAD grafting provides better long-term results
than does either CABG with other types of conduits or
CBI.14,19,30
Grafts constructed from the radial artery may also be
associated with superior postoperative survival, freedom
from adverse events, and long-term graft patency compared
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FIGURE 46.6. Incisions are made in the aorta for the proximal
anastomoses.
46
FIGURE 46.7. Proximal anastomosis of the right coronary artery
bypass graft.
FIGURE 46.8. Saphenous vein graft to
the left circumflex system. (A) The left
anterior descending coronary artery
(LAD) is identified and incised. The incision is enlarged with a Potts scissors. (B)
The probe is passed into the distal LAD
to ensure patency. (C) The distal anastomosis is created by attaching the heel of
the graft to the proximal portion of the
artery, from outside the artery to inside
the vein. Left-side suturing is completed
around the toe of the graft to approximately the midportion of the right side
of the artery. (D) The other end of the
suture is then sutured from the heel of
the graft, passing the vein to the artery.
The graft is then tied in the midportion
of the artery. (E) To expose the obtuse
marginal artery, the heart is retracted to
the right by an assistant. The obtuse
marginal branch is then incised. (F,G)
Anastomosis of the obtuse marginal
(OM) branch is begun at the proximal
portion of the artery, placing the heel of
the graft to the proximal portion of
the artery. Suturing is accomplished on
the left side of the graft, from outside the
artery to inside the vein. The anastomosis is completed on the right side by
suturing from outside the vein to inside
the artery. The sutures are usually tied
at or near the apex. (H) The aorta is
incised. (I) The proximal anastomoses
are completed.
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su rgic a l t r e atm e n t of corona ry a rt e ry dise a se
FIGURE 46.9. Technique for obtaining the internal mammary
artery (IMA) for use as a bypass conduit. (A) The IMA is mobilized
from the chest wall with cautery. Parallel incisions are made on
each side of the pedicle, which includes the vein, artery, lymphatics,
fascia, and muscle. (B) Only the tissue around the IMA should be
handled with forceps. The distal intercostal arteries and branches
are electrocoagulated. Metal clips or ligatures are placed on the
proximal branches. (C) The distal portion of the pedicle around
the IMA has been removed, and a metallic clip has been placed on
the distal mammary artery. Metallic clips are used to gain hemostasis of the pedicle without trauma to the artery. (D) The pedicle
is cleaned of its distal portion, and the artery is exposed. (E) A solution of papaverine (30 mg/100 mL) is injected into the mammary
artery with a syringe. Papaverine solution is also applied to the
pedicle. (F) After the graft is dilated, flow is assessed. If flow is less
than 60 to 100 mL/min, a more proximal portion with a higher flow
rate should be obtained. (G), The LAD is isolated, and the graft is
aligned. (H) The anastomosis is completed. Care must be taken to
ensure proper alignment of the graft on the myocardium, especially
with respect to the pericardium, the pleura, the lung, and the beating
heart.
LIMA
LAD
FIGURE 46.10. Angiogram showing a left internal mammary artery
(LIMA) graft to the left anterior descending coronary artery (LAD),
which confers a survival advantage over saphenous vein grafts.
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Percent
100
90
80
70
60
50
40
30
20
10
0
0 Yrs
5 Yrs
10 Yrs
15 Yrs
FIGURE 46.11. Data from a large coronary artery bypass grafting
study by Tatoulis et al. show the 15-year patency rates of coronary
conduits made from the left internal mammary artery (diamonds,
n = 1345), right internal mammary artery (boxes, n = 605), radial
artery (triangles, n = 177), and saphenous vein (circles, n = 3714).
46
with saphenous vein grafts,26,31–33 although there is not total
agreement on this point.34–36 Additionally, endoscopic harvesting of radial artery segments has recently been introduced and appears to produce good results (Fig. 46.12).37–39
However, there is some evidence that radial grafts are less
effective when used to graft noncritically stenosed vessels or
the right coronary artery.29,33,40–42
Cardiopulmonary Bypass
One of the chief obstacles to producing favorable outcomes
after CABG is the effects of cardiopulmonary bypass (CPB)
(Figs. 46.13 and 46.14). Although CPB and cardioplegia
remove motion and blood from the surgical field, contact
FIGURE 46.12. Videoscopic radial artery harvest allows the artery
to be removed through a 3-cm incision at the wrist. At many centers,
radial artery conduits are thought to be superior to saphenous vein
conduits and are used in most cases.
between blood and the artificial materials within the CPB
pump can provoke a systematic inflammatory response (SIR)
that may cause coagulopathy, third-space fluid retention,
and impaired end-organ function, which can lead to significant morbidity in patients with preexisting end-organ
dysfunction.43
Several technical innovations have been made in an
attempt to reduce the negative impact of CPB. These include
reducing contact between blood and the CPB mechanism by
coating the internal surface with heparin or other polymers,44–46 minimizing hemodilution by shrinking the bypass
circuit to reduce the amount of crystalloid prime needed to
start CPB,47 and using hemofiltration to protect the heart and
end organs.48,49 Preliminary evidence suggests that preoperative administration of antiinflammatory drugs reduces SIR
FIGURE 46.13. The modern heart-lung
machine is highly evolved, with
computer-controlled pumps and state-ofthe-art materials and design.
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su rgic a l t r e atm e n t of corona ry a rt e ry dise a se
Cardioplegia deuvery line
Aortic vent
Suction
Non-vented
male luer cap
Aortic canulae
Cardioplegia line
Pressure gauge
Suctioh line
Male luer sup
Arterial line
Strajght connector
with luer
Arterial fkl ter purge line
Syringe
Venous
cannulae
Vented female
luer cap
2-way
stopcock
Saphenous
vein cannulae
saphenous
vein clamp
3-way
stopcock
Color-coded tape
CP
LO
KCL
Bubble
sensor
Monitor line
Blooo
Y connector
with luer
O5 RL
Prebypass fil ter
1-way
valve
Pressure
transducer
100 mm hg
Straight
connector
1/4* perfusion
adapter connector
Arterial
blood gas
sensor
Ph - 7.40
PCO2 - 40
PO2 - 100
Air aspirator
needle
Retrograde
cannulae
Arterial filter
bypass
Diaphrgam
Vent line
Rressure
isolator
CP
LO
KCL
Arteperial
filter
Male luer lock
Cardioplegia filter
Cable tie
hand
tension
Vented male lueer cap
Over safety
rpessure valve
Cable tie
cut
Transfusion
filter
100
Perfusion
adapter set
Stopcock
Spike
Female luer
Roberts clamp
Y connector
-30
Pressure
oisplay
set
70%
O2 SAT
Praidprime
line
Softy
Hemoconcentrator
Venous uhe
Venous
saturation
connector
Postive pressure
Caroioplegia pressure
reuef line
pruef valve
4000
3000
2400
2000
1600
1000
800
400
200
100
20
Haro shell
venous
reservolr
Negative
pressure
reuef valve
Level
sensor
Membrane
osygenator
Vacuum
reoul ator
HF-6000
LIFESTRE AM
Vacuum line
Moisture
trap
Cardioplegia
Cardioplegia
temp
Vacuum une
Vacuum
gauge
Membrane
Purge
Gas blender/
Flowmeter
Oxygen
filter
Oxygen
Cardioplegia
bridge
Oxygen line
Blood cardiplegia line
Membrane
recirculation
line
Arterial
temp
Gas
outlet
Large bore
male luee
large bore
female luee
RL
Pump
header
Nonvented
cap
Reducer
connector
Apterial line
Venous/arterial
100/RPM
Forward
Hot/cold
water
Cardiac suction
30
RPM
Vent suction
20
Forward
RPM
Forward
Stop
Stop
Stop
Reverse
Reverse
Reverse
Roller pump
4:1 cardioplegia
10
RPM
Forward
Stop
Reverse
Cranr/turner/2001
Hot/cold
water
Hard shell
roller pump circult
FIGURE 46.14. A schematic of a cardiopulmonary bypass (CPB)
circuit. The particular components of CPB circuits vary in several
ways according to the individual patient’s circumstances and the
surgeon’s preferences, including the type of pump (roller vs. centrifugal) and reservoir (open vs. closed) used, and the routes by which
cardioplegia is delivered.
and may improve surgical outcomes.50–53 Avoiding the use of
cardiotomy suction devices (which tend to induce hemolysis)
has also been tried with some success,54,55 and some evidence
suggests that using a cell saver instead of a cardiotomy reservoir reduces lipid microembolization56 and improves the
biocompatibility of the bypass circuit.57 Finally, there is the
option to forgo CPB altogether.
whose grasping surfaces have suction ports that improve
their grip without the need for greater downward force; and
capture-type stabilizers, fenestrated platforms through which
silicone elastic tapes are passed, looped under the coronary
artery, and pulled tight to hold the epicardium against the
underside of the platform (Figs. 46.15 to 46.17).
Off-Pump Coronary Artery Bypass
Current U.S. estimates (based on industry reports) suggest
that 18% to 25% of CABG procedures are performed without
the use of CPB. The majority of these procedures are performed by a small percentage of heart surgeons who specialize in off-pump coronary artery bypass (OPCAB); the majority
of surgeons perform OPCAB in less than 5% of patients
requiring bypass surgery.
Technical Aspects
Keeping the coronary arteries in place during beating-heart
bypass necessitates using one of three types of coronary stabilizers: compression-type stabilizers, which use two-pronged
forks that grasp the epicardium on either side of the artery
to be bypassed; suction-type stabilizers, which use forks
CAR046.indd 1061
FIGURE 46.15. Some stabilizers use a combination of silicone
elastic tapes under the artery and a fenestrated platform to provide
a motionless, blood-free field.
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FIGURE 46.16. A number of self-retaining stabilizers are commercially available. When used correctly, these allow multivessel bypass
to be performed safely and reproducibly in the majority of patients.
The blood-free, motionless field these devices provide allows anastomotic precision very similar to what is achieved with cardiopulmonary bypass and an arrested heart.
In some patients, the left hemisternum can block the
surgeon’s view of the proximal obtuse marginal and posterolateral branches of the circumflex arteries, making it
difficult to graft coronary arteries onto the lateral and posterolateral areas of the heart. Attempts to correct this problem
by forcing the heart to the right with stabilization devices
may compromise both blood flow and stability. However,
several devices and techniques have been developed to
improve exposure while maintaining hemodynamic stability during OPCAB. Deep pericardial sutures (Fig. 46.18), first
described by Lima,58 can be tightened to create a pericardial
46
FIGURE 46.18. Sutures placed deep in the pericardial sac, when
tightened, facilitate rotation of the heart up and to the right. This
rotation allows off-pump bypass to be performed to the inferior and
lateral aspects of the beating heart without hemodynamic compromise in most patients.
ridge that supports the base of the lateral left ventricle, allowing the heart to be rotated to the right so that the apex points
upward through the sternotomy incision. This provides adequate exposure of the lateral and inferior left ventricle. Apical
suction devices, which enable the surgeon to pull the apex
of the heart away from the base and pivot the cardiac axis,
can also be used for this purpose; animal studies have shown
that these devices are as effective as deep pericardial
sutures59,60 and may cause less hemodynamic interference.59
When it is difficult to expose the lateral wall, right pleurotomy and right vertical pericardiotomy (Fig. 46.19) may be
used in addition to deep pericardial sutures to allow the
heart to herniate into the right pleural space while maintaining right ventricular end-diastolic volume (Fig. 46.20). Performing asymmetric right hemisternal elevation in addition
to the preceding techniques permits even greater lateral wall
exposure, bringing the proximal obtuse marginal and posterolateral branches into the center of the operative field.
Results of Off-Pump Coronary Artery Bypass
FIGURE 46.17. The Octopus stabilizer (Medtronic, Minneapolis,
MN) uses suction to grip the epicardial surface so that less downward pressure is required, which improves the stability of the coronary artery in some situations.
CAR046.indd 1062
As stated in the 2004 American Heart Association guidelines, there is not yet complete agreement about the relative
safety and efficacy of OPCAB and conventional CABG with
CPB.61 The difficulty in comparing the two approaches stems
in part from the low incidences of mortality and significant
morbidity associated with both techniques.62–73 A large prospective randomized trial (i.e., with 1000 patients or more)
has not been performed to date. However, a meta-analysis of
37 randomized, controlled trials of OPCAB suggests that it
is associated with significantly decreased transfusion and
inotrope requirements, atrial fibrillation, respiratory infec-
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su rgic a l t r e atm e n t of corona ry a rt e ry dise a se
FIGURE 46.19. Vertical pericardiotomy allows the heart to be
rotated into the right chest to facilitate exposure of the posterior
and lateral aspects during off-pump coronary artery bypass. This
technique is particularly useful in patients with large hearts.
tions, ventilation time, intensive care unit stay, hospital
stay, and overall in-hospital and (1-year) postdischarge costs
compared with standard CABG.21 These findings may be
explained by the results of several small randomized trials,
which suggest that OPCAB is associated with lower postoperative isoenzyme of creatine kinase with muscle and brain
units (CK-MB)73–75 and troponin levels,73,76 and less activation
of complement factors C5a and TCC77 than is standard
CABG. Additionally, these studies suggest that OPCAB
patients may have less blood loss during surgery75 and a
higher postoperative hematocrit.73 They may also be less
likely to require postoperative transfusions of red cells or
clotting factors, or to require reoperation for bleeding.73,76
Furthermore, reports of several large, retrospective, nonrandomized multicenter series indicate that OPCAB is associated with a lower incidence of death, stroke, and intraaortic
balloon pump requirement and a shorter average time on
ventilator and length of hospital stay compared with conventional CABG performed at the same institutions.62,64,65,67–70,72
National database statistics show a similar trend,66,71 as do
meta-analyses of randomized and nonrandomized comparisons of CABG and OPCAB.78,79 Additionally, a recent study
suggests that OPCAB and percutaneous angioplasty with
sirolimus-coated stents are associated with similar early and
late mortality rates, but that OPCAB patients have a lower
rate of reoperation and return of angina.80 Finally, among
CABG and OPCAB patients surveyed an average of 10.8
months after surgery, OPCAB patients reported having better
physical functioning and emotional well-being.81
Although selection bias cannot be ruled out as a potential
confounding variable in these data, a study in which propensity scores (based on major cardiac and noncardiac morbidities) were used in an attempt to decrease the impact of
selection bias also showed that OPCAB produces results
CAR046.indd 1063
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superior to those of standard CABG.82 Furthermore, a study
of patients not considered to be at high risk for CPB who were
randomized to CABG or OPCAB showed that the OPCAB
patients had less need for postoperative mechanical ventilation and had shorter intensive care unit and hospital stays.83
However, these data do not account for intraoperative findings that might make surgeons more likely to choose CPB,
such as small, calcified, diffusely atherosclerotic coronary
arteries, intramyocardial or intra-adipose coronary arteries,
or other conditions that make revascularization more
complex. Surgeons who include these considerations in their
clinical decision-making may tend to choose conventional
CABG for technically difficult revascularizations.
Despite these potential biases in the data, existing studies
nonetheless strongly suggest several advantages of OPCAB
over conventional CABG. These include a decrease in postoperative coagulopathy and a reduced need for postoperative
transfusion, which have been found consistently in virtually
all OPCAB series reported to date.62–73 These findings may
be attributable to the lower heparin requirements and preservation of platelet function associated with OPCAB, as a
prospective randomized study has shown.73
Early OPCAB procedures were limited in terms of the
adequacy of revascularization and the quality and reproducibility of the distal anastomosis, leading surgeons to perform
slightly fewer grafts in OPCAB patients than in conventional
CABG patients.68,69 However, subsequent refinement of
devices and techniques for lateral and inferior wall exposure
(vide supra) has enabled surgeons experienced with OPCAB
to perform grafts to all aspects of the heart, and more recent
series show no difference in the average number of grafts
constructed.73 Furthermore, several series have shown excellent graft patency,72,84,85 although at least one has not.76
Several retrospective nonrandomized series have shown
that OPCAB may be associated with decreased operative risk
in some high-risk groups,62,86–88 including elderly patients,
patients with reduced ejection fraction, and patients with
FIGURE 46.20. Elevating the right half of the sternum and widely
opening the right pleura and pericardium allows the heart to be
rotated into the right chest, producing excellent exposure of the
obtuse marginal territory. This patient experienced little hemodynamic compromise with this maneuver.
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chapter
renal failure.63,89–93 Furthermore, several reports have
associated OPCAB with decreased risk in repeat CABG
patients.94–96 This is because reoperative OPCAB often can
be performed without dissecting out the ascending aorta
or manipulating diseased grafts. It is less clear whether
OPCAB is better than standard CABG for patients with left
ventricular dysfunction.97,98
In dealing with heavily diseased but patent vein grafts,
many surgeons reject OPCAB because of the risk of graft
embolization while the heart is being repositioned. However,
in patients with patent LIMA-to-LAD grafts, a tailored left
thoracotomy approach for reoperative grafting of the lateral
wall allows the construction of a graft from the descending
thoracic aorta to the lateral wall branches and avoids the
potential complications of LIMA-graft mobilization.99,100
Similarly, lower sternotomy and upper abdominal incisions
have been described for constructing grafts to the inferior
wall with the right gastroepiploic artery.101,102 Long-term
patency data for these types of grafts are not yet available.
Off-pump bypass is ideal for patients with significant
atheroma or calcification of the ascending aorta. In these
cases, free grafts are attached either to the side of the in-situ
LIMA, as first described by Tector et al.,103 or to the innominate artery if it is disease-free. Alternatively, free grafts can
be attached to a disease-free area of the aorta with an automated anastomotic device or a clampless anastomotic facilitator that obviates the need for a partial-occluding clamp.
Palpation and epiaortic echo, when used together, can frequently identify an appropriate dime-sized area of relatively
normal aorta. OPCAB enables relatively easy revascularization of these high-risk patients and avoids the certain hazards
of cannulation and cross-clamping of the diseased aorta.
Neurocognitive Functioning After Off-Pump
Coronary Artery Bypass
The incidence of new onset of subtle neurocognitive dysfunction (NCD) after CABG has been reported to be between 5%
and 60%, depending on the sensitivity of the tests used.
Specific deficits include short-term memory loss, impaired
performance of simple calculations, and personality and
mood disturbances.104–106 Many factors related to CPB have
been implicated in post-CABG NCD, including the SIR,
alterations in cerebral blood flow, and microembolization
caused by the CPB circuit or by cannulation and crossclamping.106,107 Indeed, diffusion-weighted magnetic resonance imaging studies have shown that 26% to 45% of
patients recovering from CABG with CPB have focal, ischemic brain lesions.108–110 Additionally, a study of 312 CABG
patients showed that more than 17% had retinal infarcts.111
A few studies have shown that OPCAB is associated with
a reduced incidence of NCD compared with conventional
CABG with CPB.107,112 However, other studies have shown no
significant differences.113–115 Although several groups have
reported that OPCAB is associated with significantly less
SIR than is CABG,63,116,117 the magnitude of SIR has not been
shown to correlate with the severity of NCD in individual
patients.43 The failure of OPCAB to reduce postoperative
NCD has been largely attributed to the liberation of microemboli during application and removal of the partialocclusion aortic clamp. Although OPCAB eliminates the
need for a perfusion catheter for CPB or a cross-clamp for
CAR046.indd 1064
46
cardiac arrest, the side-biting partial occlusion clamp, which
is routinely used at many centers during construction of
proximal anastomoses, may be equally traumatic. However,
at least one small, randomized, prospective study has shown
that OBCAB is associated with reduced microembolization—but not a reduced incidence of NCD—compared with
standard CABG.118 Additionally, avoiding aortic manipulation by performing OPCAB using composite grafts arising
from the in-situ LIMA has been shown to reduce the risk of
postoperative stroke.119,120 Several new devices allow offpump construction of proximal anastomoses without application of the partial occlusion clamp, but it is not clear what
impact these devices will have on NCD after OPCAB.
Reducing the Invasiveness of Coronary
Artery Bypass
Although median sternotomy is a very well tolerated
incision, it does restrict patients from heavy lifting for 8
weeks and is associated with some degree of perioperative
discomfort. In addition, postoperative wound complications,
although infrequent, may require surgical revision or even
sternal resection and plastic surgical reconstruction with
tissue-transfer flaps. Patient perception of a 20-cm incision
and a “cracked” chest are also important considerations. Furthermore, some data suggest that the magnitude of musculoskeletal trauma is proportional to systemic inflammation.121,122
As such, many attempts to refine coronary bypass procedures
have focused on finding ways to decrease the size of the incision and the degree of morbidity associated with it.
Minimally Invasive Direct Coronary
Artery Bypass
First introduced by Benetti in 1995,123 the minimally invasive direct coronary artery bypass (MIDCAB) procedure
involves performing a 7-cm anterior lateral thoracotomy,
usually in the fifth intercostal space. By this route, singlevessel off-pump bypass can be performed, using the LIMA to
bypass the LAD. In several early studies, this technique
shortened hospital length of stay and reduced transfusion
requirements relative to standard CABG.99,124–126 Results of
small randomized trials suggest that, in patients with stenosis of the proximal LAD, MIDCAB is associated with a longer
in-hospital recovery period127 and higher costs than is direct
stenting,128 but that MIDCAB produces similar or better
short- and long-term outcomes.30,129 However, in the U.S.,
only a few centers regularly perform MIDCAB.
Early in the MIDCAB experience, many U.S. centers
mobilized the LIMA using direct visualization through the
thoracotomy (Figs. 46.21 and 46.22). This method was often
technically demanding, and the forceful retraction of the
chest wall necessary to expose the LIMA could cause substantial early postoperative pain. Furthermore, LIMA grafts
produced by this technique may be too short. Nevertheless,
U.S. centers that perform MIDCAB frequently report excellent results.130–132
More recently, there has been resurgent interest in videoscopic LIMA mobilization (Figs. 46.23 to 46.25). With this
technique, the left lung is collapsed while right lung ventilation is maintained, the left pleural space is insufflated with
CO2, and the LIMA is harvested from the back of the chest
11/24/2006 12:09:34 PM
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10 6 5
FIGURE 46.21. When minimally invasive
direct coronary artery bypass was fi rst being
used, surgeons harvested the left internal
mammary artery through a small anterior thoracotomy by aggressively retracting the anterior chest wall. This technique caused a great
deal of postoperative discomfort for the patient
and was sometimes technically challenging for
the surgeon.
For patients with multivessel CAD, combining a LIMA-toLAD bypass (MIDCAB) with endovascular intervention in
the circumflex and right coronary arteries may be a good
alternative to standard CABG. A multicenter series136 and a
small, single-center series137 have shown that videoscopic
mobilization of the LIMA and opening of the pericardium,
using a voice-operated robotic arm to manipulate the scope,
enables the surgeon to place the chest wall incision more
accurately. This permits construction of the LIMA-to-LAD
anastomosis without a rib spreader; instead, only soft tissue
retractors and a specially designed, bed-mounted stabilizer
are used to expose the anastomotic site through the natural
intercostal space.135 Patients are subsequently taken to the
catheterization lab where stents are placed in the circumflex
and right coronary arteries. This approach significantly
reduces postoperative pain.138
FIGURE 46.22. Diagram of the minimally invasive direct coronary
artery bypass (MIDCAB) operation, showing the typical size and
location of the incision and its position relative to the IMA-to-LAD
graft.
FIGURE 46.23. When videoscopic mammary harvest is combined
with off-pump bypass during anterior thoracotomy, the patient
experiences only modest postoperative discomfort and a favorable
cosmetic result.
wall using 5-mm videoscopic instruments. This technique
avoids the aggressive chest wall retraction required for direct
LIMA harvest and allows the entire length of the artery to
be safely mobilized. Although this technique is associated
with a significant learning curve, its success has been well
documented.133–135
Hybrid Minimally Invasive Direct Coronary Artery
Bypass/Endovascular Procedures
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46
FIGURE 46.24. When a conventional thoracoscope is coupled to a video camera and
thoracoscopic instrumentation, the internal
mammary artery can be harvested without
aggressive chest wall retraction. Single rightlung ventilation and insufflation of the left
chest with low-pressure CO2 facilitates this
technique.
Robot-Assisted Endoscopic Coronary Artery
Bypass Grafting
Several reports document totally videoscopic LIMA-to-LAD
procedures in which surgical robots were used to mobilize
the LIMA and perform the sutured anastomosis, both onpump139–141 and off-pump (Fig. 46.26).139,142,143 These robots use
master–slave servomotors and microprocessor control to precisely emulate and miniaturize the surgeon’s movements,
enabling the surgeon to manipulate videoscopic instruments
with multiple degrees of freedom (Fig. 46.27). A highresolution, three-dimensional display provides stereopsis
with a high degree of magnification (Fig. 46.28). Tremor
filtering and motion scaling can be adjusted to the surgeon’s
preferences, enabling tremendous precision, which compensates somewhat for the lack of tactile feedback (although
tactile feedback systems are under development144).
Although intriguing, surgical robots are not likely to be
in widespread use for CABG in the near future, mainly
because of the expense of the robots and the challenges
involved in learning to use them for robotic totally endoscopic CABG (TECAB), especially TECAB without CPB.
Even surgeons experienced with TECAB can perform
only one in three of them off-pump; the majority of cases
require a small MIDCAB incision in order to perform the
anastomosis.
Part of the difficulty of performing closed-chest robotic
CABG lies in the technical demands of constructing a precise
anastomosis in a confined space without the use of sutures.
(The robots’ manipulators cannot tie knots.) A number of
new tools, however, are on the horizon that may ameliorate
this problem. Several novel anastomotic devices, currently
in clinical trials, can create a precise, sutureless anastomosis
between the graft and the coronary artery (Figs. 46.29 and
46.30). If, ultimately, these produce acceptable results and
are approved for widespread use, they could make closedchest robotic CABG a practical option for the treatment of
CAD.
Port-Access Coronary Artery Bypass Grafting
FIGURE 46.25. Thoracoscopic view of the left internal mammary
artery from inside the left chest. Generally, any segment of the left
internal mammary artery can be harvested using this technique,
but there is a significant learning curve.
CAR046.indd 1066
Port-access cardiac surgery was introduced by Heartport,
Inc. (Redwood City, CA) in 1996 as a means of reducing surgical trauma. Multifunctional catheters inserted into the
femoral artery and vein are used for CPB, balloon endoclamping of the ascending aorta, antegrade cardioplegia, and
venting the ascending aorta. Additional catheters threaded
into the left jugular vein deliver retrograde cardioplegia into
11/24/2006 12:09:35 PM
su rgic a l t r e atm e n t of corona ry a rt e ry dise a se
10 67
FIGURE 46.26. The Intuitive robot (Intuitive
Surgical, Inc., Sunnyvale, CA) has a remote
console that provides the surgeon with excellent three-dimensional stereopsis and effectors
for manipulating the robotic instruments in a
very intuitive environment. The bedside
robotic component is connected to the console
by cables.
the coronary sinus and vent the pulmonary artery. This
enables the surgeon to make only a small chest incision suitable to the desired procedure.
Although port-access CPB has been used successfully in
multivessel CABG performed through small fifth intercostal
space thoracotomies,145–147 this procedure has fallen out of
favor, partly because of the difficulty of constructing grafts
of appropriate length and lie. Nonetheless, port access is still
used in some TECAB procedures and is helpful in limitedaccess mitral and atrial septal defect repairs.
FIGURE 46.27. The Intuitive robot uses sophisticated microprocessor control and master–slave servos to emulate the motion of a
human hand. This ingenious mechanism provides seven degrees of
freedom, enabling surgeons to learn quickly to manipulate the
effectors.
CAR046.indd 1067
FIGURE 46.28. Closed-chest bypass without an incision, using
robotic telemanipulation instruments, has been performed at only
select centers, mostly outside the United States. Although this
approach is currently considered technically demanding, new developments in anastomotic devices, closed-chest stabilization, and
robotic technology may one day increase its applicability.
11/24/2006 12:09:36 PM
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46
gests that OPCAB has advantages for at least some patients.
As CABG technology is refined further, less invasive techniques of LIMA-to-LAD grafting may become practical,
perhaps paving the way for new hybrid approaches to the
treatment of CAD.
References
FIGURE 46.29. The Converge anastomotic device (Converge
Medical, Sunnyvale, CA) allows a graft to be attached to a coronary
artery in an end-to-side fashion with an automated mechanism.
Anastomotic devices of this type may prove essential in the evolution of less invasive variants of coronary artery bypass grafting.
Summary
The excellent results provided by CABG, especially when
the LIMA is used to graft the LAD, are well documented.
Although there have been significant advances in the field
of catheter-based intervention, to date none has matched the
long-term patency of the LIMA graft. Moreover, there are not
yet long-term data (i.e., 10 or more years of follow-up) on
drug-eluting stents. Although there is not complete agreement about the relative safety and efficacy of OPCAB and
conventional CABG with CPB, considerable evidence sug-
FIGURE 46.30. Postoperative angiogram showing a widely patent
saphenous vein graft to the obtuse marginal coronary artery
constructed with the Converge anastomotic device (Converge
Medical).
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