Article

4.1 Minimally invasive coronary artery bypass with right gastroepiploic artery

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... When the RGEA is used in coronary artery bypass grafting (CABG), operative mortality between 0.4% to 3.3% has been reported [Suma 1991, Mills 1993, Nishida 1994, Jegaden 1995, Suma 1996, with patency rates of 96% at two months, 92% at two years [Granjean 1994], and 82% at five years [Voutilainen 1996]. The RGEA has also been used for minimally invasive coronary artery bypass grafting [Suma 1993, Voutilainen 1998. In these cases, the RGEA is anastomosed to the right coronary artery (RCA) or the posterior interventricular branch (PIV) through a small laparotomy incision with removal of the xiphoid [Suma 1993, Voutilainen 1998. ...
... The RGEA has also been used for minimally invasive coronary artery bypass grafting [Suma 1993, Voutilainen 1998. In these cases, the RGEA is anastomosed to the right coronary artery (RCA) or the posterior interventricular branch (PIV) through a small laparotomy incision with removal of the xiphoid [Suma 1993, Voutilainen 1998. This procedure could be even less invasive if the RGEA were to be harvested laparoscopically. ...
... The use of the RGEA in coronary surgery has been associated with acceptable morbidity and mortality [Suma 1991, Nishida 1994, Jegaden 1995, Mills 1996, Suma 1996. Patency rates of 92% at two years [Granjean 1994] and 82% at five years [Voutilainen 1998] have been reported. Already the RGEA has been harvested through a small laparotomy in minimally invasive bypass procedures [Suma 1993, Voutilainen 1998. ...
Article
The ultimate goal of coronary artery bypass grafting (CABG) is the performance of a totally endoscopic procedure using multiple arterial conduits. At our center we have been routinely performing endoscopic robotic harvesting of internal thoracic arteries (ITAs) for use in minimally invasive CABG. The right gastroepiploic artery (RGEA) has been shown to be a reliable and versatile arterial conduit for bypass to coronary vessels not easily accessible by an ITA. The RGEA has already been harvested less invasively through a small laparotomy. This procedure could be made even less invasive by harvesting the RGEA laparoscopically, but this procedure has not yet been reported. The purpose of this study was to develop an endoscopic technique for harvesting the RGEA and demonstrate the safety and efficacy of this less invasive approach. Twenty Duroc X Hampshire swine were administered general anesthesia and intubated. Ten mm and 5 mm trocars were then inserted. A 10 mm, 30-degree endoscope was adapted to a voice-activated robotic arm (AESOP), and the RGEA was harvested totally endoscopically using 5 mm harmonic scalpel shears. Intraoperative events and RGEA harvest times were recorded, and RGEA flows were measured after harvest. RGEA was delivered into the pericardial sac endoscopically. All RGEAs were successfully harvested without injury. Harvest time averaged 29.9+/- 10.9 min. The harvested conduits averaged 24.7+/- 2.37 cm in length. Flows were excellent in all harvested conduits, averaging 81.1+/- 31.8 cc/min. The harmonic scalpel controlled all RGEA branches with excellent hemostasis. The RGEA can be harvested safely through port access with robotic assistance. This conduit is of sufficient length to be used as an alternative arterial conduit for totally endoscopic multivessel coronary artery bypass.
Article
Background Coronary artery bypass grafting (CABG) is one of the commonest cardiothoracic surgical procedures carried out in today’s day and age. Traditionally, the midline sternotomy approach was in vogue, and CABG would be done on cardiopulmonary bypass. With further advances and expertise, various procedural modifications have been made including off-pump CABG and minimally access procedures which include minimally invasive direct coronary artery bypass (MIDCAB) grafting and partial sternotomy techniques. Subxiphoid CABG is a sparingly used novel approach but nonetheless an excellent choice in many cases. Objective To study the feasibility of minimal access subxiphoid CABG and its outcomes in patients. Materials and methods We used the subxiphoid approach in seven cases from June 2014 to date. Patients were followed up prospectively and evaluated for various factors which included post-op pain scores, healing and graft patency. Results This technique is very useful and has various advantages. Blood loss was found to be less. Healing was found to be faster and hospital stay comparably shorter. Conclusion The subxiphoid approach for CABG is a novel advancement in this surgery and is a true minimal access procedure which includes doing the CABG through a small incision, just starting below the xiphisternum and extending below to less than 3 inches. Direct CABG is done through this approach including multivessel grafting and gastroepiploic artery harvesting. We hereby would like to describe this advancement in the field of cardiac surgery.
Article
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Transdiaphragmatic off-pump coronary artery bypass grafting (OPCAB) to the right coronary artery, is an effective way to reduce the risks of second bypass surgery as well as the risk of graft injury after coronary artery bypass grafting (CABG). We report two cases of successful OPCAB as re-do surgery in which the right gastroepiploic artery (RGEA) was grafted to the right coronary artery. The first case was a 58-year-old woman, who underwent CABG 10 years ago. OPCAB (RGEA to right coronary artery) was performed since myocardial perfusion scintigraphy revealed ischemia in the inferior wall. The second case was a 67-year-old man who had hypertension, hyperlipidemia, peripheral arterial disease, and was undergoing dialysis (for 6 years). Six years previously, he developed a mycotic aneurysm of the right coronary artery and underwent open-heart surgery. He often had episodes of angina at night or during dialysis, and then developed congestive heart failure and was hospitalized. Since ischemia was considered to be in the inferior wall, the RGEA was grafted to the right coronary artery.
Article
Use of the minimally invasive direct coronary artery bypass grafting (MIDCAB) technique has been associated with excellent primary results, and sparing of resources has been assumed. There is, however, a limited amount of information available concerning the results of mid-term follow-up. The purpose of this study was to present 1-year follow-up results of our first 130 consecutive MIDCAB patients. MIDCAB operations, defined as no sternotomy, no cardiopulmonary bypass, and no aortic manipulation were started in our clinic in February 1996. One hundred thirty patients requiring invasive treatment of coronary artery disease who were not suitable for percutaneous transluminal angioplasty were included in this series. The main outcome measures were mortality, the need for subsequent invasive treatment, and 1-year NYHA classification. There was one hospital death, but during the first-year follow-up, four additional deaths occurred and three patients were reoperated on with conventional techniques. Five percutaneous transluminal coronary angioplasties (PTCAs) had to be performed, two because of anastomosic stenosis. Additionally, cardiac- or operation-related symptoms caused a total of 27 hospital visits among 23 patients during the first-year follow-up. Angiographic left internal thoracic artery (LITA)-left anterior descending artery (LAD) patency was 97.4% (37/38) (confidence interval [CI] ranged from 86.2% to 99.9%) at 3 months. After 1 year, 86.9% (113/130) of the patients were without symptoms. A clear improvement of the follow-up results was observed to be associated with increased experience during the study period. MIDCAB operations, after some experience, can be performed with relatively good outcome. However, special attention should be directed to determination of correct anastomosic site and to avoiding anastomosic stenosis. We also recommend extended mobilization of the ITA and use of specific stabilizers.
Article
Target vessel revascularization on a beating heart via a mini subxiphoid incision, not only eliminates the hazards of sternal reentry, but also avoids the detrimental systemic effects of extracorporeal circulation. The goal of the study was to develop and describe a safe and effective method to revascularize the right coronary artery in reoperative cases, using beating heart and minimally invasive techniques in lieu of the RGEA. There were three men and four women with a mean age of 69 years; four were second time reoperations and three third time reoperations. Through a subxiphoid approach, a lower ministernotomy is performed. Once the coronary target is established, a Rultract retractor is used to gently elevate the right half of the sternum to take down the RITA. A mechanical stabilizer was used to provide stabilization for distal anastamoses. Flow was measured in all the grafts with the Medi-Stim before and after protamine administration. [table: see text] We believe that this technique provides another effective approach to the patient who requires reoperative coronary revascularization of the RCA.
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We present 2 patients who underwent transabdominal minimally invasive direct coronary artery bypass with the right gastroepiploic artery combined with abdominal aortic aneurysm repair. The surgical procedures, both performed through a median laparotomy, proved safe and of limited invasiveness. The one-stage surgical intervention prevented catastrophic complications, such as acute myocardial infarction or rupture of abdominal aortic aneurysm. We believe that concomitant transabdominal minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair should be considered as a single combined surgical strategy in selected patients.
Article
Patients with patent grafted bilateral internal thoracic arteries may require repeat myocardial revascularization because of either progression of disease in a nongrafted native vessel or failure of a saphenous vein graft. In order to avoid extensive dissection and possible damage of the internal thoracic arteries, we elected to proceed with an off-pump minimally invasive direct coronary artery bypass grafting (MIDCABG) approach using the pedicled right gastroepiploic artery. This paper summarizes our midterm angiographic results. From 1996 to 2003, 15 patients were reoperated on using this approach in our department. Internal thoracic artery grafts always revascularized the anterior and lateral territories and were angiographically patent. Indications for repeated surgery were: (1) coronary disease progression in 8 patients; (2) occlusion of the saphenous vein graft in 6 patients; and (3) anastomotic stenosis of a pedicled right gastroepiploic artery in 1 patient. Off-pump grafting of the pedicled right gastroepiploic artery was targeted at the posterior descending artery in 14 patients, and at the left anterior descending artery in 1 patient. Thirty-day mortality was 6.5% (1 of 15 patients). With a mean follow-up of 56 +/- 20 months, angina-free survival was 79%. At angiographic control (mean, 38 months), the pedicled right gastroepiploic artery was patent in 13 patients. One patient had an occluded right gastroepiploic artery graft at 23 months and another patient showed progression of disease distal to the right gastroepiploic artery anastomosis at 28 months. Off-pump MIDCABG repeat revascularization with a pedicled right gastroepiploic artery is an effective method of revascularization for patients with patent bilateral internal thoracic arteries.
Article
The right gastroepiploic artery (RGEA) has been used as a conduit in coronary artery bypass grafting. Although some reports presenting good results justify its use in clinical settings, there is still much concern about using the RGEA in bypass surgery. The RGEA demonstrates different behaviors from the internal thoracic artery (ITA) in bypass surgery due to its histological characteristics and anatomical difference, which might contribute to the long-term outcome. Now that left ITA (LITA) to left anterior descending artery (LAD) is the gold standard, other grafts are expected to cover the rest of the coronary arteries. It should be elucidated how we can use other grafts and what we can expect from them. RGEA, as an arterial graft, can be used as an in situ graft or a free graft. The RGEA is mainly used to graft to the right coronary artery (RCA) because of its anatomical position, and its patency is not inferior to that of the saphenous vein (SVG). The RGEA can cover the lateral walls when its length is long enough or by making a composite graft with other grafts. However, when used to graft to the LAD, its mid-term patency is not favorable.
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