How to Achieve Full Minimally Invasive Revascularization with Two Internal Thoracic Arteries

Mikhail Snegirev4, Evgeniy Minin2, Vladimir Noginov2, Ekaterina Golovacheva2, Naim Mirpochoev3 and Vidadi Efendiev1,3

1KVMT Beloostrov, Saint-Petersburg, Russia, 2Mariinsky hospital, Saint-Petersburg, Russia, 3Heart Team Clinic, Khujand, Tajikistan, 4Medion Innovation Clinic, Tashkent, Uzbekistan

 

BACKGROUND Minimally invasive coronary bypass surgery in its different variations is a popular operation with excellent outcomes [1]. However, most of the groups use venous grafts for non-LAD territories. In this study, we demonstrate how left and right internal thoracic arteries (ITA) may be configured in order to achieve full arterial revascularization via the left minithoracotomy.

MATERIAL AND METHODS Between January 2016 and December 2024 190 patients with stable multivessel coronary artery disease were operated via left-minitoracotomy. In these patients only ITA grafts were used. No conduits were harvested from extremities. All operations were conducted off-pump using different types of rib retractors with chest wall elevators. and myocardial stabilizers (vacuum or non-vacuum tissue stabilizers). Apical stabilizing devices were not used. ITA harvesting and Y-graft formation was accomplished under direct vision or with endoscopic assistance.

RESULTS All patients received full myocardial revascularization. In 171 patients revascularization was achieved only by ITA grafts. In 78 cases ITAs were used as in situ grafts where right ITA (RITA) revascularized LAD system and left ITA (LITA) anastomosed to the left-sided branches. In the remaining 93 cases we harvested RITA as a free graft and used it as a Y-graft with LITA. In this scheme, RITA length was usually enough to graft circumflex branches sequentially and even reach PDA. In 9 cases when RITA length was scarce we used venous or radial conduits. The overall number of the patients who underwent postoperative CT coronary evaluation is 18. Median follow-up was 22,7 ± 11,8 months. Among 46 investigated grafts only 2 had signs of disfunction (competitive flow). Thus, the patency rate was 95.6 %. The length of the operations was 212 ± 61 minutes. There was no perioperative mortality in this series.  

CONCLUSION Minimally invasive multivessel bypass grafting may be safely performed via left minithoracotomy. The most useful configuration when more than 2 targets are required – is composit Y-/T-graft configuration. Endoscopic assistance may be useful for achieving better visualization.

Reference: 1. VerevkinA, Von Aspern K, Tolboom H, Gadelkarim I, Etz C, Misfeld M, Borger MA, Davierwala PM. Total Arterial Multivessel Minimally Invasive Coronary Artery Bypass Surgery: 5-Year Outcomes. Ann Thorac Surg. 2024 Nov;118(5):1044-1051