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MMCTS
(August 9, 2005). doi:10.1510/mmcts.2004.000778 Copyright © 2005 European Association for Cardio-thoracic Surgery Procedure Left anterior small thoracotomy procedureDivision of Cardiac Surgery, University "G. D'Annunzio", S. Camillo de Lellis Hospital, via Forlanini 50, 66100 Chieti, Italy * Corresponding author: * Tel.: +39-087-135 8628; fax: +39-087-135 7552. E-mail: bothe{at}ch11.ukl.uni-freiburg.de
The left anterior descending (LAD) artery off-pump grafting with the left internal mammary artery (LIMA), via a left anterior small thoracotomy (LAST operation) introduced, for the first time, by Vasilii Kolesov in 1964, gained popularity in the second half of the 1990s. Patients with single LAD disease (not suitable for interventional treatment) or patients showing multi-vessel disease with the other coronaries occluded and refilled by collateral circulation, but not graftable because of technical issues, can be considered candidates for this type of operation. The incision is performed at the 4th intercostal space. Pectoralis and intercostal muscles are dissected and the pericardium is opened. The LIMA is harvested as a pedicle up to the clavicle to reach a more distal and/or more lateral anastomotical site. After the stabilizer has been positioned, the LAD is incised and an intracoronary shunt is inserted. The anastomosis is then performed on a beating heart. Finally, the anastomosis is checked by means of a transit-time flowmeter. The intercostal space is then closed in a standard fashion, leaving a drainage inside. In our experience, 853 patients underwent the LAST operation. Early mortality rate was 1.2% with a nine-year survival of 91.3±1.0.
Key Words: Left anterior descending (LAD) • Left anterior small thoracotomy (LAST) • Left internal mammary artery (LIMA)
History Off-pump left anterior descending (LAD) grafting using left internal mammary artery (LIMA), via a standard left anterior thoracotomy, was introduced for the first time in 1964 by Vasilii Kolesov [1]. It has been an isolated experience until the 1990s, when a group of surgeons called Benetti, Acuff, Robinson, Subramanian and Calafiore [2,3,4,5,6] reproposed the same procedure with only a few modifications. The most important being a minimal invasive access (left anterior small thoracotomy, LAST operation). The possibility to revascularize the most important coronary artery, using the most important arterial conduit [7], generated a great deal of interest, even if some concerns about technical aspects and midterm results have been overcome only in the second half of the 1990s, with the advent of different stabilization systems [8] and the publication of fairly good midterm results [9].
Surgical indications Patient with single LAD disease
Patients with multiple-vessel disease Assuming that the LAD lesion is suitable for surgery, the other coronary vessels should be:
Anatomical contraindications
Anesthetical management
The patient is positioned on the operating table in the supine position as usual. No pillar is required as the patient is set up on his back in the usual fashion. The operation begins with the skin incision at the 4th intercostal space or, in case of a female patient, on the submammalian groove. The pectoralis muscle edge is divided from the fifth rib, so disclosing the fourth intercostal space (Video 1).
The pleural space is then opened from the lateral towards the medial direction, taking care not to damage the internal mammary artery pedicle, usually running 1–2 cm away from the left sternal border (Video 2).
The pericardium is then incised over the LAD on the guide of the finger, that is usually slit over the heart surface, from the right to left ventricle. The LAD course is usually located in the area where the increase in stiffness is felt. Once the epicardial course of the artery is confirmed, the pedicle isolation then starts with the aid of an 8.5 inch Teflon coated cautery tip (Video 3).
Before the procedure is started, the left lung is taken away using wet swabs. In order to accomplish the harvesting a proper retractor (ACCESS MPTM Lift – MMCTSLink 54) is used to raise the upper chest, making the mammary course more visible (Video 4).
Videoscopy is not required as harvesting is possible under direct vision (we decided to use a videoscopic system just for better demonstrating either the pedicle isolation or the anastomotic technique). In order to take into account the anatomical variability of the LAD position or to cope with a distal anastomotical site, two different plains of dissection have to be considered. The frontal one is important with respect to a chance of reaching a more lateral LAD (Video 5).
The sagittal plain allows the chance to reach a more distal site (Video 6).
The first step of the IMA isolation is a deep cautery incision, running about 1 cm laterally to the artery from the first rib to the chest opening (Video 7).
Starting from the chest opening, the pedicle is progressively isolated from lateral to medial and from caudal to cranial direction, cutting every arterial or venous branch between two hemoclips (Videos 8,9,10).
After mobilization of the IMA, collateral blood flow could reach the sternum by way of a sternal/intercostal (S/I) IMA branch. For this to occur, the point of division of the S/I branch into its sternal and intercostal sub-branches must be protected, clipping distally the common trunk of the collateral branch (Video 9) [12]. The isolation so carried out guarantees that the graft is not jeopardized by the lung excursion. In fact a very proximal IMA isolation beyond the chest curvature towards the clavicle produces a pedicle lying on the mediastinal pleura below the anterior margin of the lung (Video 11).
The following step is the epicardial adipose tissue flap preparation (Video 12) which is very useful to protect from above either the pedicle or the anastomosis, so avoiding development of direct adhesions with the chest wall.
A possible further operation done by median sternotomy will find the pedicle almost free to be gently dissected. The satellite veins are both ligated and the tip of the mammary artery skeletonized (Video 13).
After cutting the pleural remnants along the medial aspect of the pedicle according to the distance towards the anastomotical site, a solution 1:10 of papaverine in saline is injected into the mammary artery via a 20G olive-tipped needle. The mammary is then allowed to dilate after the distal end is ligated with a hemoclip (Video 14).
A 5/0 prolene is then passed around the LAD proximally to the chosen anastomotical site. The stabilizer (ACCESS MVTM – MMCTSLink 54) is positioned and the artery is incised after proximal snaring (Video 15).
A soft intracoronary shunt (MMCTSLink 55) is then positioned and the artery unclamped. The arteriotomy is then adjusted in length. A couple of additional stay-sutures are passed through the epicardium on both sides of the anastomotical site to better stabilize the area (Video 16).
After the LIMA tip has been prepared the anastomosis is started (Video 17).
The LIMA is approximated to the LAD after the first stitches on the heel. The anastomosis is then completed and the suture is tied on the left side of the contour (Video 18).
The functioning of the anastomosis is checked by means of a transit time flowmeter (MMCTSLink 56). The pedicle is covered with the adipose tissue flap previously created in order to protect it from strong adhesion to the chest wall. The thoracotomy is closed in a standard fashion leaving a chest drainage inside (Video 19).
In our Institution, from November 1994 up to December 2002, 853 LAST operations have been performed. Mean age was 61.5±10.1 years. Patients with single vessel disease were 384 whereas 469 patients had multivessel disease. In the first group mean EuroSCORE was 3.0% (median 1.7%) vs. 4.0% (median 2.3%) in the second group, P=0.003.
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Summary
Introduction
1 month) angiographic patency rate and perfect patency rate [
