Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging

doi:10.1016/0003-4975(96)00416-X

The Annals of Thoracic Surgery

Volume 62, Issue 2, August 1996, Pages 591-593

https://doi.org/10.1016/0003-4975(96)00416-X Get rights and content

Minimally invasive direct coronary artery bypass grafting offers mortality and morbidity advantages to selected patients. To broaden indications for such, an appropriate and combined disciplinary approach using angioplasty and minimally invasive direct coronary artery bypass grafting is described in a patient requiring reoperative grafting. Documentation of patency of new left internal mammary artery-to-left anterior descending artery anastomoses performed without the use of cardiopulmonary bypass was obtained intraoperatively using a Thermal Imaging Camera.

References (8)

BenettiFJ et al.
Direct myocardial revascularization without extracorporeal circulation
Chest
(1991)
StanbridgeR et al.
Minimal-access surgery for coronary artery revascularization [Letter]
Lancet
(1995)
AromKV et al.
Mini-sternotomy for coronary artery bypass grafting
Ann Thorac Surg
(1996)
MohrFW et al.
Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery
Ann Thorac Surg
(1989)

There are more references available in the full text version of this article.

Cited by (37)

Off-pump coronary artery bypass grafting and other minimally invasive techniques
2005, Revista Espanola de Cardiologia
Aunque la cirugía coronaria sin el uso de circulación extracorpórea (CEC) se realizó por primera vez hace más de 40 años, no ha sido hasta la segunda mitad de la década de los noventa y merced a un importante desarrollo tecnológico cuando se ha convertido en una técnica estandarizada y reproducible. A pesar de todo, hay una importante confusión terminológica entre las diferentes variantes de las llamadas «técnicas mínimamente invasivas ». Hay incluso importantes diferencias técnicas en la cirugía coronaria sin CEC por esternotomía media.
En el presente artículo se analizan las razones para su resurgimiento, la terminología, su evolución, las nuevas posibilidades de manejo anestésico y postoperatorio y los requerimientos técnicos clave. Nuestra concepción del problema nos ha llevado a la revascularización arterial completa con ambas arterias mamarias internas sin CEC. A sus particulares aspectos técnicos y a nuestros resultados con los 1.000 primeros pacientes se dedican apartados del artículo. Finalmente, se comentan las evidencias científicas sobre sus resultados analizadas en la Conferencia de Consenso de París ISMICS-2004: la cirugía coronaria sin CEC, en manos expertas, es igual de segura y efectiva que la convencional, reduce algunos aspectos de la morbilidad y, en estudios no aleatorizados pero sí ajustados, la mortalidad en pacientes de alto riesgo.
Although coronary surgery was first carried out without the use of extracorporeal circulation more than 40 years ago, it was not until the second half of the 1990s and thanks to an important technological development that it became a standardized reproducible technique. There is significant terminological confusion between the different forms of so-called minimally invasive technique. There are even important technical variations in off-pump coronary surgery involving median sternotomy. The present article reviews the reasons for this renaissance, the terminology used, current progress, key technical requirements, and new developments in anesthesia and postoperative management. Our approach to the technique has resulted in us carrying out full arterial revascularization in the beating heart using both internal mammary arteries. Part of this article is devoted to the specific technical details of this form of revascularization and to the results obtained in our first 1000 patients. Finally, we comment on the scientific evidence concerning coronary surgery without extracorporeal circulation that was reviewed at the ISMICS Consensus Conference in Paris in 2004: in expert hands, coronary surgery without extracorporeal circulation is just as safe and effective as conventional surgery, reduces some forms of morbidity, and, according to nonrandomized but adjusted studies, decreases mortality in high-risk patients.
Infrared thermography: A rapid, portable, and accurate technique to detect experimental pneumothorax
2004, Journal of Surgical Research
Pneumothorax (Ptx) is a life-threatening complication that can result from trauma, mechanical ventilation, and invasive procedures. Infrared thermography (IRT), a compact and portable technology, has become highly sensitive. We hypothesized that IRT could detect Ptx by identifying associated changes in skin temperature.
Bilateral nonpenetrating chest incisions or needle punctures were performed in 21 anesthetized rats. Rats were then randomized to no, bilateral, left, or right Ptx by either open (n = 16) or closed percutaneous (n = 5) puncture through selected pleurae. Real-time thermographic images and surface temperature data were acquired with a noncooled infrared camera.
In all cases, blinded observers correctly identified each Ptx with real-time grayscale image analysis. When compared to either the ipsilateral baseline or an abdominal reference, experimental Ptx produced a significantly greater decrease in surface temperature when compared to non-Ptx control.
These results demonstrate that portable infrared imaging can rapidly and accurately detect changes in thoracic surface temperature associated with experimental pneumothorax.
Novadaq SPY: Intraoperative Quality Assessment in Off-Pump Coronary Artery Bypass Grafting
2004, Chest
Citation Excerpt :
To address this need, several techniques have been developed in an attempt to achieve adequate quality control during surgery. Mohr et al10 and Emery et al11 demonstrated the clinical impact of thermal coronary angiography. In a large study population,10 they reported early IMA graft failure in 6.2% of cases.
Off-pump coronary artery bypass grafting may decrease operative morbidity when compared to on-pump bypass grafting; however, it is technically demanding and thus quality control is essential. This study assesses the clinical feasibility of a new, indocyanine green (ICG)-based imaging system (SPY; Novadaq Technologies; Toronto, ON, Canada) to monitor the quality of anastomoses and grafts in off-pump revascularization.
Thirty-eight consecutive patients undergoing nonemergent coronary artery bypass grafting without the use of extracorporeal circulation at two Swiss cardiac surgery clinics were included. On completion of bypass grafts, the quality of the grafts was assessed using the ICG-based imaging system. The imaging device comprises an 806-nm laser light source that is used to cause ICG to fluoresce and a near infrared-sensitive charged couple device videocamera that is used to capture the fluorescence images. ICG was administered through the central venous line, and images were acquired during the first pass of the ICG through the field of view. Graft flow (qualitative) and the quality of the grafts and anastomoses were assessed intraoperatively.
Between March 2002 and September 2002, a total of 38 patients (26 men and 12 women; mean ± SD age, 64.6 ± 10.5 years; body mass index, 27.1 ± 2.9) underwent surgery and imaging at two institutions. One hundred seven of 124 grafts (45 arteries and 62 veins) were analyzed. Seventeen grafts could not be assessed due to difficulties in positioning. The imaging system was easy to handle, and no adverse reactions to ICG were observed. Four of the 107 grafts imaged required revision (three anastomotic constrictions and one graft dissection). Each imaging sequence required approximately 1.25 to 2.5 mg of ICG. The images were equivalent to angiography without the need for radiographs and catheter insertion. In addition, the course of coronaries that would otherwise be difficult to locate in obese patients could be detected using the imaging system. Biochemical and ECG data demonstrated an absence of intraoperative or postoperative myocardial damage, and no liver enzyme elevation or renal dysfunction.
This study supports the clinical utility of a ICG-based imaging system for the assessment of the quality of bypass grafts, which appears to be safe and simple to use.
Opposite trends in coronary artery and valve surgery in a large multisurgeon practice, 1979-1999
2004, Annals of Thoracic Surgery
Citation Excerpt :
Parallel developments in “minimally invasive” CAB technology, including off-pump CAB (OPCAB), have taken place mainly in the last half of the 1990s. OPCAB was quickly adopted and refined by several surgeons in our group [11]. These early adopters or visionaries[12] of new technologies profoundly influenced the conduct of CAB in our group, resulting in an increase of up to 28.9% OPCABs by 1999.
Trends in coronary artery bypass (CAB) and valve operations (VO) may help predict the future of cardiac surgery in the context of changing case mix, shifting paradigms, emerging technology, and population demographics.
We retrospectively reviewed all 30,319 adult CAB and VO in our group from 1979 to 1999 according to specific procedures.
Coronary artery bypass volumes peaked in 1996 at 1,895 cases, declining 15.3% to 1,605 cases in 1999 with a decrease in risk profile and percent reoperations and an increase in mean age and percent octogenarians, prior percutaneous coronary interventions (PCI), left internal mammary artery (LIMA) graft usage, off-pump technology usage, and hospital mortality of reoperations. Right internal mammary grafts were employed infrequently and radial artery grafts transiently. Overall VO volumes continued to increase 24.0% since 1996, from 470 to 583 cases with a decreased risk profile, increased mean age, and percent octogenarians and prior PCI. The percentage of mechanical valve implants decreased, while the percentage of various tissue solutions for valve disease increased. Limited access incisions and port-access were employed transiently with CAB and VO.
Coronary artery bypass volumes are decreasing, with an increasing percentage of LIMA grafts and off-pump cases. Valve operation volumes are steadily increasing, with a decreasing percentage of mechanical valve implants, in favor of various tissue solutions.
Coronary hybrid revascularization from January 1997 to January 2001: A clinical follow-up
2002, Annals of Thoracic Surgery
Background. Hybrid revascularization (HyR), combining minimally invasive left internal mammary artery (LIMA) bypass grafting to the left anterior descending coronary artery (LAD) and catheter interventional treatment of the remaining coronary lesions, avoids the disadvantages associated with cardiopulmonary bypass (CPB). We investigated the clinical follow-up of 57 patients with multivessel disease undergoing this procedure in the last 4 years.
Methods. Between January 1997 and January 2001, 57 consecutive patients (41 men and 16 women, aged 65.7 ± 7.9 years) with coronary artery disease (two-vessel, n = 34; three-vessel, n = 23) were treated with off-pump LIMA-to-LAD bypass combined with balloon angioplasty and stenting of the remaining significantly obstructed (> 50%) coronary vessels. Clinical follow-up data included a early postoperative and a 6-month control angiography and a patient interview in January 2001.
Results. All patients underwent LIMA-to-LAD bypass-grafting and balloon angioplasty in 72 coronary lesions without procedural-related complications. However, one early LIMA bypass occlusion was documented during coronary angiography. Postoperatively no deterioration of preexistent organ dysfunction was observed in any patient. The mean follow-up was 100.7 ± 37.9 weeks in 55 of 57 patients (97%). Control angiography 6 months after HyR (n = 34) revealed a patent LIMA bypass in 33 patients and 8 in-stent restenoses (> 50%) in the coronary arteries that were treated interventionally by re-PTCA (n = 6) or by conventional CABG (n = 1). In 1 patient medical treatment resulted in significant reduction of angina so no further intervention was considered necessary. After HyR 1 patient died 18 months later of an intracerebral hemorrhage. All other patients are alive and doing well.
Conclusions. Our results indicate that in selected patients with multivessel disease including left main stem stenosis HyR is an effective and secure procedure with excellent early and good midterm results. Especially elderly patients with severe concomitant diseases appear to benefit from this approach by avoiding CPB.
The coronary artery bypass conduit: II. Assessment of the quality of the distal anastomosis
2001, Annals of Thoracic Surgery
Citation Excerpt :
In all, 19 (5.3%) IMA graft occlusions were identified and revised. Similar observations have been reported during both MIBCAB and OPCAB procedures as well using an endoscopic TCA camera [22–25]. Angiography to assess coronary anastomotic patency after MIDCAB historically has been performed in a fixed standard cardiac catheterization laboratory either immediately after [26] or during the first several days postoperatively [27].
The outcome of coronary artery bypass grafting procedures is highly dependent on the technical adequacy of the distal anastomosis. Various methodologies, including flow measurement and imaging techniques, have been used by the cardiothoracic surgeon to assess the adequacy of the distal anastomosis. The limitations of these techniques outweigh their advantages and limit their widespread clinical applicability. Recent improvements in the technique for online measurement of regional myocardial pH provide a promising new metabolic approach to assessing the adequacy of the distal anastomosis in cardiac surgery.

View all citing articles on Scopus

View full text

Case reportRevascularization using angioplasty and minimally invasive techniques documented by thermal imaging

Chest

Lancet

Ann Thorac Surg

Ann Thorac Surg

Case report
Revascularization using angioplasty and minimally invasive techniques documented by thermal imaging