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J Thorac Cardiovasc Surg 2004;127:1525-1527
© 2004 The American Association for Thoracic Surgery

Brief communication

Modified minimally invasive coronary artery bypass after radical treatment for left breast cancer

Toshiya Ohtsuka, MDa,*, Mikio Ninomiya, MDa, Takahiro Nonaka, MDa, Taisei Maemura, MDa

a Department of Cardiovascular Surgery, Tokyo Metropolitan Fuchu General Hospital, Tokyo, Japan

Received for publication October 15, 2003; revisions received November 5, 2003; accepted for publication November 10, 2003.

* Address for reprints: Toshiya Ohtsuka, MD, 2-9-2 Musashidai, Fuchu-shi, Tokyo 183-0042, Japan
ootsuka-cvs{at}fuchu-hp.fuchu.tokyo.jp

Minimally invasive coronary artery bypass (MICAB) customarily means off-pump coronary artery bypass with a limited approach and is generally performed through a left anterior small thoracotomy by using the internal thoracic artery (ITA).1 This communication describes a modified MICAB technique with a video-assisted left subcostal approach, in which the left anterior descending artery (LAD) was revascularized with a saphenous vein (SV) graft by using an inflow from the right axillary artery. This procedure was applied to a female octogenarian who had undergone a radical left mastectomy and adjunctive radiation therapy for advanced left breast cancer.

Methods

An 81-year-old woman presented with unstable angina caused by an LAD lesion for which surgical intervention was indicated. Twenty years before, the patient had undergone a left mastectomy and extensive left axillary lymph node dissection because of advanced left breast carcinoma. The soft tissue component (adipose tissue and muscle) over the sternum and the left anterior bony structures had been completely removed, and the resulting skin defect over the midsternum and the left breast had been repaired by means of autograft implantation (Figure 1). Thereafter, adjunctive radiation therapy had been performed over both ITAs and the dissected left axillary area. Although there had been no cancer recurrence over the following 2 decades, ulceration had occurred repeatedly on the ischemic skin over the thin chest wall, and therefore the left anterior small thoracotomy and sternotomy approaches were inapplicable. Furthermore, angiography showed that both irradiated ITAs were very small and that the left axillary artery, which lay in the extensively dissected and irradiated region, was inappropriate as an inflow for the bypass graft.



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  		Figure 1. Photograph of patient's chest showing right subclavicular (4 cm) and left subcostal (6 cm) skin incisions (arrows) and auto-skin graft over sternum and left breast (arrowheads).

 
The patient was placed in the supine position, and general anesthesia was obtained through a single-lumen endotracheal tube. A 6-cm left subcostal skin incision was made parallel to the costal arch (Figure 1), and the left abdominal rectal muscle and the left anterior part of the diaphragm were divided. The pericardium was opened, and the mid-LAD was exposed, retracting the left costal arch anteriorly. Palpation demonstrated that the small right gastroepiploic artery was inappropriate as a bypass graft, and therefore the SV was harvested and anastomosed to the right axillary artery through a 4-cm subclavicular skin incision (Figure 1). The SV graft was advanced to the heart with videoscopic assistance by using a 10-mm, 30° rigid scope; the graft penetrated the first intercostal space, passed the right pleural cavity, and finally crossed the retrosternal space to be anastomosed to the mid-LAD. The SV-LAD anastomosis was performed on the beating heart with a stabilizer fixed to the operating table. The subcostal wound was closed, repairing the divided muscles.

Results

The operating time was 2 hours and 50 minutes, and there was no procedure-related morbidity. Angiography performed on the seventh postoperative day confirmed the patency of the SV graft (Figure 2).



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  		Figure 2. Postoperative angiography of SV graft (arrowheads) from right axillary artery (A) to LAD (arrows).

 
Discussion

A modified MICAB through the extrathoracic entry (ie, a transabdominal approach) has been reported to provide satisfactory clinical results in patients with multivessel disease.2 Subramanian and Patel2 suggested that a sufficient direct view of the heart could be obtained through the bottom of the thorax if the abdominal rectal muscle was divided, and traction of the costal arch was accordingly released. The present left subcostal approach for establishing a single bypass to the LAD is, in fact, a modified and limited version of their approach. Videoscopy enhanced the limited view through this abdominal minientry and was used for graft control; the SV graft from the apical intrapleural cavity through the retrosternal space was visualized in its entirety, and its pathway was verified on the video monitor.

Axillocoronary artery bypass through the minimally invasive approach has been reported to be an alternative technique to the standard ITA-MICAB in a limited number of patients, such as redo cases.3,4 In comparison with the standard aortocoronary bypass, a longer graft is needed, and the long-term graft durability is unknown. Meticulous follow-up is therefore important. In these patients the patent SV graft can be detected easily and repeatedly in the infraclavicular area by using transcutaneous echocolor Doppler scanning.5 Although the present patient has been free of angina for 6 months after the MICAB, the patency of the graft has been checked every 3 months with Doppler scanning.

In summary, a modified MICAB to the LAD involving an SV graft with right axillary arterial inflow and a video-assisted left subcostal approach was successfully accomplished in a patient with previous radical treatment for left breast cancer. Although the present method is strictly limited to only specific patients, it can be a viable alternative to the classical MICAB procedure.

References

  1. Stanbridge RD, Symons GV, Banwell PE. Minimal-access surgery for coronary artery revascularisation. Lancet. 1995;346:837[Medline]
  2. Subramanian VA, Patel NU. Transabdominal minimally invasive direct coronary artery bypass grafting (MIDCAB). Eur J Cardiothorac Surg. 2000;17:485–487[Abstract/Free Full Text]
  3. Coulson AS, Glasgow EF, Bonatti J. Minimally invasive subclavian/axillary artery to coronary artery bypass (SAXCAB): review and classification. Heart Surg Forum. 2001;4:13–25[Medline]
  4. Yaryura R, Vardhan R, Springer AJ, Cooley DA. A 66-year-old man with severe angina and previous coronary artery bypass. Lancet. 1997;349:396[Medline]
  5. Ohtsuka T, Suematsu Y, Kubota H, Takamoto S, Makuuchi M. Salvage of right gastroepiploic artery graft before pancreatoduodenectomy. J Thorac Cardiovasc Surg. 2001;121:1013–1014[Free Full Text]




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