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Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement
Published on: March 26, 2018
[Policy of using the right internal thoracic artery "in situ" for coronary artery bypass grafting]
Iu Iu Vecherskiĭ1, S L Andreev1, V V Zatolokin1
1Department of Cardiovascular Surgery, Research Institute of Cardiology under the Siberian Branch of the Russian Academy of Medical Sciences, Tomsk, Russia.
Insights
This study demonstrates that the right internal thoracic artery (RITA) "in situ" can be safely used for coronary artery bypass grafting (CABG) of the right coronary artery (RCA) system. Composite grafting with RITA and radial artery (RA) offers effective revascularization without aortic manipulation.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Grafting
Background:
- Coronary artery bypass grafting (CABG) is a critical procedure for treating coronary artery disease.
- The use of "in situ" arterial grafts, particularly the internal thoracic artery (ITA), offers advantages over vein grafts.
- Optimizing graft length and surgical technique for "in situ" right ITA (RITA) and radial artery (RA) utilization is essential for successful outcomes.
Purpose of the Study:
- To evaluate the outcomes of coronary artery bypass grafting using "in situ" right internal thoracic artery (RITA) for the right coronary artery (RCA) system.
- To assess the efficacy of composite bypass grafting utilizing the proximal RITA and radial artery (RA).
- To analyze the morphometric characteristics of radial artery segments and the impact of spasm prevention protocols.
Main Methods:
- Analysis of 73 patients undergoing CABG with "in situ" RITA.
- Specific assessment of RITA length conformity for RCA grafting in 14 patients.
- Evaluation of RITA grafting through the pleural cavity in 16 patients.
- Bilateral mammary composite grafting with RA in 43 patients.
- Comparative morphometric examination of 22 RA segments.
- Analysis of 56 cases using RA with a pharmacological spasm prevention protocol.
- Statistical analysis using the Mann-Whitney criterion (p<0.05).
Main Results:
- "In situ" RITA can be used for RCA bypass grafting with low complication rates (7.1% at 1.5 years) when anatomical landmarks are met.
- Grafting RITA through the pleural cavity is feasible with no complications after 1 year.
- Composite grafting with proximal RITA and RA achieves high revascularization latency (94.7% at 3 years), avoids aortic manipulation, and preserves RITA sternal beds.
- Skeletonized RA segments showed increased wall thickness (1.38±0.05 mm) versus non-skeletonized (1.09±0.04 mm) under low osmotic pressure.
- Pharmacological spasm prevention in RA grafts resulted in low complication rates (1.75% MI, 7% angina relapse at 3 years).
Conclusions:
- "In situ" RITA is a viable option for RCA revascularization, with specific techniques minimizing graft tension and complications.
- Composite grafting strategies involving RITA and RA expand bilateral mammary grafting possibilities, overcoming limitations of bilateral "in situ" ITA use.
- Developed methods enhance surgical options for coronary revascularization, improving patient outcomes and reducing postoperative complications.
Abstract:
The authors analysed the outcomes in a total of 73 patients subjected to coronary artery bypass grafting with the use of the "in situ" the right internal thoracic artery. Of these, 14 patients endured bypass grafting with assessment of the conformity of the length of the "in situ" right ITA as a conduit for the distal third of the right coronary artery (RCA). 16 patients underwent grafting of the RITA "in situ" with the RCA by passing through the pleural cavity. The remaining 43 patients were subjected to bilateral mammary composite bypass grafting using the radial artery (RA). A total of 22 segments of the RA were subjected to a comparative morphometric examination depending on the method of exposure. We additionally analysed 56 cases of utilizing the RA with the use of the pharmacological protocol of preventing spasm. The results were regarded statistically significant if p<0.05. We used the non-parametric criterion of Mann-Whitney. The obtained results showed that the right ITA "in situ" may be used for bypass grafting of the RCA system, excluding the risk of graft tension, if the perpendicular from the 6th intercostal space crosses the sharp edge of the heart 1.5-2 cm distal to the medial point, with the minimum number of complications after 1.5±0.3 years (7.1%). When the above-mentioned perpendicular is located proximal to the middle point of the sharp edge of the heart it is possible to use the right ITA "in situ" for the RCA system thanks to passing the conduit through the right pleural cavity under the anterior segment of the upper lobe and the medial segment of the middle lobe of the right lung with no complications after 1 year. The method of composite bypass grafting by means of the proximal segment of the right ITA "in situ" and the RA makes it possible to effectively revascularize any portions of the coronary bed (latency 94.7% after 3.0±0.8 years), to avoid manipulations on the aorta, and to save the bed of the right ITA in the middle and distal third of the sternum with no postoperative complications. It was revealed that in the conditions of decreased osmotic pressure the increase in the thickness of the vascular wall is more pronounced in the skeletonized segments of the RA (1.38±0.05 mm) as compared with the segments surrounded by connective and fatty tissue (1.09±0.04 mm). The pharmacological protocol for prevention of radial artery spasm used in 56 patients resulted in a small number of complications observed after 3.0±0.8 years (myocardial infarctions - 1.75%, angina pectoris relapse - 7%). Hence, the developed methods of using the right ITA "in situ" widen possibilities of bilateral mammary bypass grafting, excluding the existing problems of routine use of the both ITAs "in situ".
