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Left internal thoracic artery harvesting in pleural symphyses under minimally invasive direct vision
K Morishita1, Y Tamiya, K Komatsu
1Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Japan.
Insights
Minimally invasive direct coronary artery bypass grafting (MIDCAB) is challenging with dense pleural adhesions. An extrapleural tunnel approach successfully harvested the internal thoracic artery (ITA) in a patient with severe adhesions, enabling successful bypass surgery.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Minimally Invasive Procedures
Background:
- Minimally invasive direct coronary artery bypass grafting (MIDCAB) utilizes the internal thoracic artery (ITA) for coronary anastomosis.
- Harvesting the ITA can be complicated by dense pleural adhesions, particularly in patients with prior thoracic surgery or inflammation.
- Standard MIDCAB techniques may be hindered by adhesions, potentially increasing operative risks.
Observation:
- A patient with extensive pleural adhesions, resulting from a pulmonary resection 40 years prior due to tuberculosis, was considered for MIDCAB.
- The adhesions were so severe that entering the intrapleural space was impossible using standard videothoracoscopic or direct-vision techniques.
- An alternative surgical strategy was required to safely harvest the ITA.
Findings:
- An extrapleural tunnel approach was successfully employed to harvest the ITA, circumventing the dense adhesions.
- This modified technique required increased operative time and resulted in more bleeding compared to standard procedures.
- Despite the challenges, a successful anastomosis between the ITA and the left anterior descending coronary artery was achieved.
Implications:
- MIDCAB procedures are feasible even in patients with significant pleural adhesions, previously considered high-risk or unsuitable.
- The extrapleural tunnel technique offers a viable alternative for ITA harvesting in complex thoracic cases.
- This approach expands the application of MIDCAB, potentially improving outcomes for a broader patient population with challenging adhesions.
Abstract:
In minimally invasive direct coronary artery bypass grafting (MIDCAB), the internal thoracic artery (ITA) is harvested under a direct-vision or videothoracoscopic techniques. However, whatever the technique used, dense pleural adhesions hamper ITA harvesting. We describe the case of a patient who underwent MIDCAB 40 years after a pulmonary resection for tuberculosis. The parietal pleura adhered to the left lung so firmly that we could not enter the intrapleural cavity. Therefore, the ITA was harvested creating an extrapleural tunnel Although this approach resulted in more operating time and bleeding, an anastomosis between the ITA and left anterior descending coronary artery was performed successfully. We believe that MIDCAB can be carried out even in patients with dense pleural adhesions.