Avulsion of the Left Internal Mammary Artery After Minimally Invasive Coronary Bypass

doi:10.1016/S0003-4975(96)01265-9

The Annals of Thoracic Surgery

Volume 63, Issue 3, March 1997, Pages 843-844

https://doi.org/10.1016/S0003-4975(96)01265-9 Get rights and content

Abstract

Minimally invasive direct coronary artery bypass grafting is a relatively new procedure. An unusual complication occurred in a patient after a period of heavy lifting, namely, avulsion of the left internal mammary artery graft. He presented with a clinical picture of myocardial infarction and shock. Diagnostic work-up and surgical management are described.

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During minimally invasive coronary artery bypass grafting, great care is taken to ensure adequate length and smooth course of the conduit. The LIMA pedicle is routinely sutured to the epicardium to prevent torsion about the anastomosis. The initial presentation of this patient was ischemia and infarction. We assumed that the LIMA had occluded due to technical problems, such as injury to the artery during dissection, obstruction of the distal anastomosis, or kinking of the graft. The mechanism

References (1)

AM Calafiore et al.
Left anterior descending artery grafting via left anterior small thoracotomy without cardiopulmonary bypass
Ann Thorac Surg
(1996)

Cited by (18)

Avulsion of the left internal mammary artery graft after minimally invasive coronary surgery [4] (multiple letters)
2001, Annals of Thoracic Surgery
Surgical myocardial revascularization without cardiopulmonary bypass
2000, Annals of Thoracic Surgery
Citation Excerpt :
Furthermore, the limited access obtained during minithoracotomy precluded adequate mobilization of LIMA and required lengthening with inferior epigastric artery [3]. Though with improved techniques this is not required [18], midsternotomy always ensures proper length of LIMA which not only improves quality of anastomosis but can also prevent catastrophic complication of LIMA-LAD anastomotic disruption due to short IMA, as has been reported [18, 30]. Incomplete revascularization has been clearly identified as a main contributor to higher hospital mortality and morbidity and early return of angina [22, 33–35].
Background. Though coronary artery bypass grafting (CABG) without cardiopulmonary bypass is being performed with increasing frequency, in the absence of adequate angiographic follow-up, safety, reproducibility, and efficacy of the procedure remain doubtful. In this prospective study, we report the results obtained by 100% angiographic follow-up of 96 consecutive patients.
Methods. A total of 96 patients (age range 33 to 76 years) underwent CABG without cardiopulmonary bypass. Single vessel disease was present in 46 (47.9%) patients, double vessel disease in 31 (32.3%), and triple vessel disease in 19 (19.8%) patients. All patients were operated through a standard midsternotomy and an optimal combination of pharmacological and mechanical methods were used to restrict cardiac movements during anastomosis. All patients underwent coronary angiography before discharge from the hospital.
Results. A total of 160 grafts were placed (range 1 to 4 grafts per patient, average 1.7 ± 0.3 grafts per patient). A single graft was placed in 46 patients, double grafts in 38, triple grafts in 10, and quadruple grafts in 2 patients. Various grafts included pedicled left internal mammary artery (LIMA) (n = 95), free LIMA (n = 1), right internal mammary artery (n = 14), radial artery (n = 24), right gastroepiploic artery (n = 5), and saphenous vein grafts (n = 21). Operative mortality was 1.0% (1 of 96). Two patients required reoperation for excessive bleeding. Mean hospital stay was 5.7 ± 1.2 days. Overall angiographic patency was 95.0% with LIMA patency of 97.9% (93 of 95). One patient with block in midsegment of LIMA was reoperated using cardiopulmonary bypass. Follow-up ranged from 4 to 17 months (mean 8.2 ± 3.1 months). Two patients (one with narrowed LIMA to left anterior descending artery anastomosis, and one with patent anastomosis) had residual angina.
Conclusions. Coronary artery bypass grafting without cardiopulmonary bypass is a reproducible, effective, and safe option in selected group of patients. A conscientious approach in patient selection and route of operation is required.
Con: Beating-heart surgery for coronary revascularization: Is it the most important development since the introduction of the heart-lung machine?
2000, Annals of Thoracic Surgery
Citation Excerpt :
In another series [15], a third of the patients had angiographic evidence of graft occlusion within 24 hours after undergoing BHCABG via a minimally invasive incision. McMahon and coauthors observed avulsion of the IMA 5 days after a similar procedure, and other surgeons have had unreported anecdotal instances of this complication [17]. In the early experience of Gundry and associates [18], BHCABG (with a full sternotomy) was considered for all patients in need of myocardial revascularization.
Contrary to what the media tend to suggest, beating-heart coronary artery bypass grafting (BHCABG) is not a new technique. It has been performed since the advent of coronary revascularization but, until recently, was largely abandoned in favor of cardiopulmonary bypass (CPB) and cardioplegic techniques. However, with the introduction of minimally invasive coronary surgery and mechanical methods for target-artery stabilization, interest in BHCABG has been renewed. In carefully selected cases, this approach has the advantages of simplicity, avoidance of the inflammatory response caused by CPB, and a decreased need for blood transfusion. Nevertheless, BHCABG may be technically difficult in some patients, and it involves a steep learning curve. Potential risks include incomplete revascularization, ischemia during temporary target-artery occlusion, and suboptimal anastomoses. Because of the need for special equipment, BHCABG can be expensive and time consuming. It may benefit older or sicker patients who are poor candidates for CPB, especially those with left anterior descending or right coronary artery lesions, but it should be used with discretion and not be considered for all coronary patients.
Avulsion of an H graft during closed-chest cardiopulmonary resuscitation after minimally invasive coronary artery bypass graft surgery
2000, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
At the end of the procedure, despite maximal inotropic support and intra-aortic balloon counterpulsation, the patient could not be separated from cardiopulmonary bypass and expired in the operating room. Avulsion of the LIMA graft from the LAD after a LAST procedure, as a result of strenuous physical activity and heavy lifting in the early postoperative period, has been previously reported in the literature by the authors' group.5 As in the case described, the exact mechanism of avulsion of the H graft pedicle remains not entirely understood.
Minimally invasive cardiac surgery: Surgical techniques and anaesthetic management
1999, Annales Francaises d'Anesthesie et de Reanimation
Faire le point sur l'état actuel de la chirurgie cardiaque mini-invasive.
Recherche dans la banque de données Medline^® des articles de langue française ou anglaise.
Les articles ont été analysés de façon à faire la synthèse des différentes techniques mini-invasives avec leurs principales indications et contreindications.
La chirurgie cardiaque miniinvasive correspond à des procédés chirurgicaux variés, dont les modalités techniques essentielles sont décrites et les avantages et inconvénients respectifs discutés. Il est important que l'anesthésiste-réanimateur connaisse avec précision les différentes étapes de chaque technique, afin d'adapter sa pratique aux conditions chirurgicales et d'assurer au patient une sécurité optimale: préservation de la fonction ventriculaire et de la perfusion systémique, détection et traitement de l'ischémie myocardique, prévention de l'hypothermie en cas de chirurgie de revascularisation coronaire à cœur battant par stemotomie, ventilation sélective termittente avec CPAP sur le poumon exclu en cas de minithoracotomie. L'acquisition d'une compétence en échocardiographie transœsophagienne est indispensable pour l'insertion et la surveillance du positionnement correct des différents cathéters du système de CEC endovasculaire Heartport^™ (cathéter de décharge pulmonaire, cathéter du sinus coronaire, canule veineuse, ballonnet d'occlusion endoaortique) permettant la chirurgie de revascularisation coronaire et la chirurgie de la valve mitrale, selon un abord thoracique réduit et finalement la surveillance de la purge complète des cavités cardiaques en cas de chirurgie valvulaire mitrale par minithoracotomie, ou aortique par ministernotomie. Dans tous les cas, l'anesthésie est réalisée avec des agents à demi-vie courte, permettant l'extubation précoce, le retour en unité chirurgicale dans un délai inférieur à 24 heures, avec mobilisation postopératoire rapide, en dépit d'une durée d'intervention souvent plus longue que lors de la chirurgie cardiaque conventionnelle.
To review current data on minimally invasive cardiac surgery.
Search through the Medline^® data base of French or English articles.
The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications.
Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positionning of the various catheters of the endovascular CPB Heartport^™ system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.
Orthotopic cardiac transplantation after minimally invasive direct coronary artery bypass
1999, Journal of Thoracic and Cardiovascular Surgery

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Case ReportsAvulsion of the Left Internal Mammary Artery After Minimally Invasive Coronary Bypass

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Ann Thorac Surg

Case Reports
Avulsion of the Left Internal Mammary Artery After Minimally Invasive Coronary Bypass