Off-pump coronary artery bypass grafting without mechanical stabilization in minipericardiotomy
http://www.100md.com
《血管的通路杂志》
Cardiothoracic Surgery Department, Policlinico ‘Multimedica’ Via Milanese, 300 Sesto S. Giovanni, Milano 20099, Italy
Abstract
Stabilization and exposure of coronary vessels in off-pump bypass grafting is achieved by means of different and expensive mechanical stabilizers. We describe a new technique of stabilization and exposure of target vessels by using only a ‘double suspension-stabilization stitch’ without the support of mechanical stabilizers. In accomplishing left anterior descending and right coronary artery off-pump bypass grafting, this technique has resulted in a good hemodynamic stability, in no epicardial damage and surgical trauma, and finally it represents a costless procedure.
Key Words: Coronary bypass; Myocardial revascularization; Off-pump coronary artery bypass grafting
1. Introduction
Recently, technical advances in coronary artery exposure and mechanical stabilization have resulted in a remarkable resurgence of interest for myocardial revascularization without cardiopulmonary bypass. Immobilization of the target coronary artery plays an important role in off-pump coronary artery bypass grafting. Stabilization of coronary targets is accomplished to date by using two categories of mechanical stabilizers: compression or suction type (1).
The aim of this report is to describe a new simple technique of exposure and stabilization of left anterior (LAD) and right coronary (RCA) arteries performed by means of only two pericardial–epicardial stay sutures, the ‘Double suspension–stabilization stitch’, through a minipericardiotomy, without using any kind of mechanical stabilizers to perform coronary bypass.
2. Materials and methods
Transesophageal echocardiography and Swan-Ganz right heart catheterization are employed for cardiac function monitorization. In 11 patients with one or two-vessel disease not suitable for PTCA, through a midline sternotomy, pericardial fatty tissue corresponding to left anterior descending artery course has been dissected. Usually, if the artery is sclerotic, it is possible to individuate its decourse by finger exploration over the pericardium. The coronary course through pericardial sac, after dissection of the pericardial fatty tissue, can be directly identified. Otherwise, LAD and RCA can be easily identified by digital exploration through a minimal pericardiotomy close to the diaphragm reflection. Careful localization of target vessel is crucial because the technique is based on a minimal pericardiotomy (usually 2 cm) exactly over the anastomotic site. An intravenous bolus of heparin (150 IU/kg body weight) is then administered. Stabilization of anastomotic site is achieved by means of vessel silicon loops with a blunt needle passed through the pericardial rims and around the coronary, with a double snare to obtain a better stabilization. The same procedure is performed proximally and distally to the anastomotic site. A gentle traction is then applied on the silastic sutures and coronary site is stretched against pericardium obtaining maximal immobilization in all directions (x,y,z), with minimal impact on cardiac function and hemodynamic stability (Figs. 1 and 2). A better stabilization can be achieved through the application of two couples of hemoclip on the point of exit of silastic suture out of the pericardium to maximize stretching of the anastomotic site against the pericardium itself. After a test occlusion of 2 min followed by another 2 min of reperfusion, coronary artery is occluded again by traction on the silastic loops. Usually, snaring of the coronary artery during construction of anastomosis is not necessary. Arteriotomy is then performed without any kind of mechanical stabilizer. Anastomosis between left internal thoracic artery (LITA) and LAD is performed with a running 7-0 monophilic suture (if needed, with an intraluminal shunt too) (Fig. 3). The same procedure can be accomplished for right coronary grafting with right internal thoracic artery by a minimal pericardiotomy performed just over the anastomotic site. A total number of 16 coronary anastomosis (11 LITAD and six RITA–RCA) have been performed.
3. Comment
Compression-type mechanical stabilizers intense pressure may affect circulatory stability and increase the distance from the anastomotic site. Sucker-type instruments do not present these problems, but they introduce vacuuming pressure that can cause epicardial damage mainly in older patients [1]. Moreover, both instrumentations increase total costs.
‘Double suspension-stabilization stitch’ is a simple technique applied in our experience in a limited number of patients with one or two–vessels (LAD and RCA) disease that has proved to be safe and effective in accomplishing off-pump coronary grafting without stabilizers. Immobilization of coronary bypass anastomotic site is guaranteed by its stretching against pericardium, a stable anatomic structure. Almost three-dimensional coronary artery stabilization was achieved in all cases. No operative mortality and no major morbidity were detected. At short-term follow-up, all patients operated or did well. Angiographic controls obtained one month after surgery showed a patent FitzGibbon grade A of LITA-LAD and RITA-RCA anastomosis [2]. This technique presents several advantages: it abolishes the risks of circulatory instability or epicardial damage, reduces blood loss and surgical trauma by means of the minipericardiotomy, and it is at zero costs. The ideal case is represented by a left anterior descending artery with a medialized course easy to expose via a limited anterior pericardiotomy or a two-vessel disease with a right coronary stenosis before crux cordis. In case of lateral displacement of LAD it can be best visualized by means of a small gauze positioned through minipericardiotomy between lateral cardiac surface and visceral pericardium to medialize the coronary course. Reinterventions are safe because the pericardial sac in the midline is completely closed. In our experience, anastomotic time does not significantly differ from bypass, which is performed with mechanical stabilizers. A comparison between our coronary stabilization procedure and the off-pump surgery with conventional mechanical devices could be performed by intravital microscopy using orthogonal polarization spectral imaging [3], a method recently employed in evaluation of different coronary stabilization concepts. In conclusion, the technique is safe and cost-effective: because of the limited number of patients, this original off-pump coronary bypass technique needs a further validation.
Acknowledgements
We are grateful to Mr Marco Balconi, RN and Mr Giuseppe Catrambone, RN for their technical assistance.
References
Konishi T, Higuchi K, Fukata M, Akisima S, Fukada S. Hybrid-Type Stabilizer for off-pump direct coronary artery bypass grafting. Ann Thorac Surg 1998;66:961–2.
FitzGibbon GM, Burton JR, Leach AY. Coronary bypass graft fate: angiographic grading of 1400 consecutive grafts early after operation and of 1132 after one year. Circulation 1978 Jun;57:1070–4.
Detter C, Deuse T, Christ F, Bohem DH, Reichenspurner H, Reichart B. Comparison of two stabilizer concepts for off pump coronary artery bypass grafting. Ann Thorac Surg 2002;74:497.(Pietro Di Biasi, Tiziano )
Abstract
Stabilization and exposure of coronary vessels in off-pump bypass grafting is achieved by means of different and expensive mechanical stabilizers. We describe a new technique of stabilization and exposure of target vessels by using only a ‘double suspension-stabilization stitch’ without the support of mechanical stabilizers. In accomplishing left anterior descending and right coronary artery off-pump bypass grafting, this technique has resulted in a good hemodynamic stability, in no epicardial damage and surgical trauma, and finally it represents a costless procedure.
Key Words: Coronary bypass; Myocardial revascularization; Off-pump coronary artery bypass grafting
1. Introduction
Recently, technical advances in coronary artery exposure and mechanical stabilization have resulted in a remarkable resurgence of interest for myocardial revascularization without cardiopulmonary bypass. Immobilization of the target coronary artery plays an important role in off-pump coronary artery bypass grafting. Stabilization of coronary targets is accomplished to date by using two categories of mechanical stabilizers: compression or suction type (1).
The aim of this report is to describe a new simple technique of exposure and stabilization of left anterior (LAD) and right coronary (RCA) arteries performed by means of only two pericardial–epicardial stay sutures, the ‘Double suspension–stabilization stitch’, through a minipericardiotomy, without using any kind of mechanical stabilizers to perform coronary bypass.
2. Materials and methods
Transesophageal echocardiography and Swan-Ganz right heart catheterization are employed for cardiac function monitorization. In 11 patients with one or two-vessel disease not suitable for PTCA, through a midline sternotomy, pericardial fatty tissue corresponding to left anterior descending artery course has been dissected. Usually, if the artery is sclerotic, it is possible to individuate its decourse by finger exploration over the pericardium. The coronary course through pericardial sac, after dissection of the pericardial fatty tissue, can be directly identified. Otherwise, LAD and RCA can be easily identified by digital exploration through a minimal pericardiotomy close to the diaphragm reflection. Careful localization of target vessel is crucial because the technique is based on a minimal pericardiotomy (usually 2 cm) exactly over the anastomotic site. An intravenous bolus of heparin (150 IU/kg body weight) is then administered. Stabilization of anastomotic site is achieved by means of vessel silicon loops with a blunt needle passed through the pericardial rims and around the coronary, with a double snare to obtain a better stabilization. The same procedure is performed proximally and distally to the anastomotic site. A gentle traction is then applied on the silastic sutures and coronary site is stretched against pericardium obtaining maximal immobilization in all directions (x,y,z), with minimal impact on cardiac function and hemodynamic stability (Figs. 1 and 2). A better stabilization can be achieved through the application of two couples of hemoclip on the point of exit of silastic suture out of the pericardium to maximize stretching of the anastomotic site against the pericardium itself. After a test occlusion of 2 min followed by another 2 min of reperfusion, coronary artery is occluded again by traction on the silastic loops. Usually, snaring of the coronary artery during construction of anastomosis is not necessary. Arteriotomy is then performed without any kind of mechanical stabilizer. Anastomosis between left internal thoracic artery (LITA) and LAD is performed with a running 7-0 monophilic suture (if needed, with an intraluminal shunt too) (Fig. 3). The same procedure can be accomplished for right coronary grafting with right internal thoracic artery by a minimal pericardiotomy performed just over the anastomotic site. A total number of 16 coronary anastomosis (11 LITAD and six RITA–RCA) have been performed.
3. Comment
Compression-type mechanical stabilizers intense pressure may affect circulatory stability and increase the distance from the anastomotic site. Sucker-type instruments do not present these problems, but they introduce vacuuming pressure that can cause epicardial damage mainly in older patients [1]. Moreover, both instrumentations increase total costs.
‘Double suspension-stabilization stitch’ is a simple technique applied in our experience in a limited number of patients with one or two–vessels (LAD and RCA) disease that has proved to be safe and effective in accomplishing off-pump coronary grafting without stabilizers. Immobilization of coronary bypass anastomotic site is guaranteed by its stretching against pericardium, a stable anatomic structure. Almost three-dimensional coronary artery stabilization was achieved in all cases. No operative mortality and no major morbidity were detected. At short-term follow-up, all patients operated or did well. Angiographic controls obtained one month after surgery showed a patent FitzGibbon grade A of LITA-LAD and RITA-RCA anastomosis [2]. This technique presents several advantages: it abolishes the risks of circulatory instability or epicardial damage, reduces blood loss and surgical trauma by means of the minipericardiotomy, and it is at zero costs. The ideal case is represented by a left anterior descending artery with a medialized course easy to expose via a limited anterior pericardiotomy or a two-vessel disease with a right coronary stenosis before crux cordis. In case of lateral displacement of LAD it can be best visualized by means of a small gauze positioned through minipericardiotomy between lateral cardiac surface and visceral pericardium to medialize the coronary course. Reinterventions are safe because the pericardial sac in the midline is completely closed. In our experience, anastomotic time does not significantly differ from bypass, which is performed with mechanical stabilizers. A comparison between our coronary stabilization procedure and the off-pump surgery with conventional mechanical devices could be performed by intravital microscopy using orthogonal polarization spectral imaging [3], a method recently employed in evaluation of different coronary stabilization concepts. In conclusion, the technique is safe and cost-effective: because of the limited number of patients, this original off-pump coronary bypass technique needs a further validation.
Acknowledgements
We are grateful to Mr Marco Balconi, RN and Mr Giuseppe Catrambone, RN for their technical assistance.
References
Konishi T, Higuchi K, Fukata M, Akisima S, Fukada S. Hybrid-Type Stabilizer for off-pump direct coronary artery bypass grafting. Ann Thorac Surg 1998;66:961–2.
FitzGibbon GM, Burton JR, Leach AY. Coronary bypass graft fate: angiographic grading of 1400 consecutive grafts early after operation and of 1132 after one year. Circulation 1978 Jun;57:1070–4.
Detter C, Deuse T, Christ F, Bohem DH, Reichenspurner H, Reichart B. Comparison of two stabilizer concepts for off pump coronary artery bypass grafting. Ann Thorac Surg 2002;74:497.(Pietro Di Biasi, Tiziano )