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J Thorac Cardiovasc Surg 1997;113:411-412
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS, PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY, AND STENT PLACEMENT FOR LEFT MAIN STENOSIS

William G. Liekweg, MDa, Ramesh Misra, MDb


Flint, Mich.

Received for publication July 22, 1996 accepted for publication Sept. 5, 1996. Address for reprints: William G. Liekweg, MD, Cardiovascular and Thoracic Surgeons, PC, 302 Kensington Ave., Flint, MI 48503.

Minimally invasive direct coronary artery bypass (CAB) is rapidly gaining acceptance in the field of cardiac surgery.Go 1 The advantages of decreased morbidity, shorter hospital stays, and recovery time are appealing to patients and surgeons. The indications and techniques for this procedure are being defined.Go 2

This article demonstrates the utility of the minimally invasive direct CAB procedure as an adjuvant therapy to allow angioplasty and stent placement for left main stenosis.

A 52-year-old man underwent cardiac catheterization for progressive angina. The results revealed 90% stenosis of the left main coronary artery, mild disease of the right coronary artery (<30% stenosis), and moderately depressed ejection fraction (Fig. 1). This man had diabetes mellitus and chronic renal failure (creatinine 9 mg/dl) for which he underwent peritoneal dialysis. He had chronic anemia (hemoglobin level 8.0 gm) but, being a devout Jehovah's Witness, refused all blood products. The initial plan was to treat the anemia with epoetin alfa (Epogen) until the hemoglobin level reached 12.0 gm and then proceed with conventional CAB grafting. However, he began to have accelerated angina necessitating a more urgent intervention.



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  		Fig. 1.

 
At operation an 8 cm parasternal incision was made. The left fourth and fifth costal cartilages were removed. An 8 cm section of the internal thoracic artery (ITA) was dissected from the left side of the chest wall and anastomosed to the midportion of the left anterior descending coronary artery (LAD) with 7-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.). Local blood flow was controlled with a 1.5 mm internal vessel occluder (Biovascular Inc., St. Paul, Minn.). Esmolol was given to slow the heart rate to 60 beats/min. A low dose of heparin (10,000 units) was administered and later reversed with a half dose of protamine. Flow in the ITA was measured at a rate of 100 ml/min. He was extubated a few hours after the operation and resumed his daily dialysis schedule. Total blood loss during the operation and the postoperative period was 110 ml.

On the fourth postoperative day he was electively returned to the catheterization laboratory, where he underwent successful angioplasty of the left main coronary artery with a 3 mm Lifestream balloon (Applied Cardiac Systems, Inc., Temecula, Calif.) after patency of the ITA-LAD graft had been verified (Fig. 2). This was followed by placement of a 3.5 mm intracoronary stent (Johnson & Johnson, Warren, N.J.) and final dilation with a 3.5 mm N.C. Bandit balloon (SciMed/Boston Scientific Corporation, Maple Grove, Minn.) (Fig. 3). Cardiopulmonary support standby was available but not used.



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  		Fig. 2.

 


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  		Fig. 3.

 
Innovative approaches to coronary disease may become more common now that minimally invasive direct CAB has become technically feasible. Our patient had numerous medical problems that made standard CAB extremely risky. We believed that if the anterior wall could be protected by the ITA graft, angioplasty could be undertaken with less risk. We did not think that the ITA would provide sufficient long-term blood flow to both the LAD and circumflex systems in the event of left main closure.

The long-term state of the ITA graft to the LAD after reopening of the left main artery is unknown. It is suspected that significant competitive flow will lead to diminution in the ITA contribution to global blood flow. The "angiographic string sign" may develop, but this does not necessarily mean closure of the ITA.

The fact that the angioplasty proceeded with no hemodynamic changes or arrhythmias indicates that the ITA was protective during brief left main occlusion with balloon inflations. This might suggest that minimally invasive direct CAB may become a bridge to complete revascularization in conjunction with percutaneous intervention for multivessel coronary artery disease.

Footnotes

From the Divisions of Cardiac Surgerya and Cardiology,b Genesys Regional Medical Center, Flint, Mich. Back

References

  1. Calafiore AM, DiDiammarco G, Teodore G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Am Surg 1996;61:1658-65.
  2. Arom KV, Emery RW, Nicoloff DM. Mini-sternotomy for coronary artery bypass grafting. Am Surg 1996;61:1271-2.



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