Federico Benetti

MINI-OPCABG an option in Hybrid coronary revascularization

Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery to left anterior descending bypass with percutaneous coronary intervention of non-left anterior descending vessels. And it is feasible and appeared to be safe, with faster recovery and similar outcomes when compared with conventional CABG

The history of off–pump coronary bypass (opcab)

Submit Manuscript | http://medcraveonline.com technology and tools to operate on the unsupported beating heart. In 1952, Demikhov described the use of the LITA to directly graft the left anterior descending in dogs, with graft patency confirmed for up to 2-years [2]. Similar early success with the use of the ITA was reported by Canadian surgeon Gordon Murray [3]. Willian Longmire was apparently the first surgeon in performing an Offpump coronary artery bypass operation. He said they performed a couple of the earliest internal mammary coronary anastomosis when they were forced into it when the coronary artery they were endarterectomizing disintegrated and in the desperation they anastomoses the left internal mammary artery to the distal end of the right coronary artery [4].

Right mammary artery and saphenous vein non touch a combination for complete off pump revascularization in coronary surgery without touching the aorta

The use of the right mammary as inflow with vein non touch or others conduits and the preservation of the LITA to LAD alone is another option for the patients that need coronary surgery in multivessels diseases without touching the aorta off pump. Surgical Technique: After we finished the left internal mammary dissection we move the mammary retractor and dissected the right mammary artery with as much length as possible in complete sternotomy, and around 5 to 6 cm at the level of the 3 or 4 intercostal space in the Mini Sternotomy. The proximal part is prepared in beak flute and 3 sutures of 7-0 prolene are place in the the proximal and distal part. After we connected the vein depending of the number and situation of the potential anastomosis we add different piece of conduits either vein of right mammary or eventually a radial artery. After finished the proximal conduits we do first the LIMA to LAD anastomosis and complete the rest of the bypasses Results: Operative mortality 0% Average hospital stay 59 hours MACE at 2 years 0%. Conclusion: More developed technique and the technology is needed to improve this operation and be able to reproduce in a big scale. Introduction The majority of the worldwide Coronary surgery typically requires exposure of the heart and its vessels through median sternotomy and cardiopulmonary bypass, making it one of the most invasive and traumatic aspects of open-chest surgery. Trying to decrease the risks of the CABG and its costs, in 1978 we popularized the Off Pump Coronary Artery Bypass Graft (OPCABG) [1,2] and expand the technique, addressing lesions of the circumflex system (Cx) and applying it to diverse clinical scenarios. We tested several surgical approaches, such as full sternotomy, including left, anterolateral, posterolateral and right anterolateral thoracotomies, as well as partial sternotomy [3]. The video – assisted techniques in the nineties allowed, for the first time, to dissect the left internal thoracic artery (LITA) without opening the pleura cavity. The LITA was anastomosed to the left anterior descending (LAD) through a small left anterior thoracotomy. [4-6] and a new method for coronary bypass was created [7]. From 1996, a new series of technological developments allowed, widespread application of the OPCABG and MIDCAB techniques surgeons to perform high quality reproducible anastomoses and demonstrate in the great majority of reports, a decrease in postoperative morbidity. In 1997, we performed for the first time an ambulatory coronary bypass through a xiphoid lower sternotomy incision (MINI OPCABG) using 3D technology to assist in the operation [8], the low incidence of atherosclerosis of the IMA in contrast to frequent atherosclerosis of the LAD was proven histologically as well as biochemically [9]. As a number of North American teams have shown, this good patency rate of the LIMA to LAD seems to be maintained at long term, which is not the case with saphenous vein bypass grafts. We know that from more than 30 years [10]. In 1975 Tector describes the technique of end to side anastomosis and published results that suggested that the IMA is an excellent graft in most coronary bypass procedures [11,12] Different variables of this original idea were described [13] and is some evidence that non touch the aorta off pump is the best option compared with conventional coronary surgery and stenting [14]. Harvesting the Saphenous Vein with the Non Touch technique conferred, at a mean time of 16 years, a significantly higher patency than the conventional technique that was still comparable to that of the LITA [15]. The used of the right mammary as inflow with vein non touch or others conduits and the preservation of the LITA to LAD alone is another option for the patients that need coronary surgery in multivessels diseases without touching the aorta off pump We know today that this option is the best alternative for patients with multivessels that need coronary surgery [16,17] In this article we described our actual technique for perform this operation [18].

Xiphoid lower-sternotomy approach for multivessel revascularization of the left internal mammary artery to the left anterior descending artery and right internal mammary artery inflow to the other vessels.

BACKGROUND We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels. OPERATIVE TECHNIQUE The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patients anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum. RESULTS Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms. CONCLUSION This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.