Hybrid Revascularization Using Percutaneous Coronary
Hybrid Revascularization Using Percutaneous Coronary
Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-left anterior descending (LAD) territories with minimally invasive direct coronary artery bypass (MIDCAB) using the left internal thoracic artery (LITA) to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to perform full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages associated with the percutaneous treatment of symptomatic coronary stenoses. We investigated whether HR was a valid alternative to conventional coronary artery bypass graft surgery in patients with multivessel coronary artery disease. We also present our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.
Minimally invasive direct coronary artery bypass (MIDCAB) has been successfully used to treat isolated lesions of the left anterior descending (LAD) artery by operating on the beating heart without cardiopulmonary bypass (CPB) with excellent medium-term results. MIDCAB involves open harvesting of the left internal thoracic artery (LITA) through a small left anterior thoracotomy incision or lower hemisternotomy incision (Figure 1). The LITA is then sewn directly to the LAD on the beating heart through this limited opening. MIDCAB has been associated with improved cosmetic results and quicker recovery time when compared with traditional sternotomy. Likewise, the avoidance of CPB spares the patient the risks associated with activation of the complement, coagulation and fibrinolysis systems and alterations in red blood cells, leukocytes and platelets, which may result in bleeding and thromboembolic complications, such as stroke. MIDCAB is also associated with a lower cost than coronary artery bypass grafting (CABG). It may be the preferred choice of surgical revascularization in elderly, comorbid and reoperated patients with type B or C lesions.
(Enlarge Image)
Minimally invasive direct coronary artery bypass (MIDCAB) involves open harvesting of the left internal thoracic artery (LITA) though a small left anterior thoracotomy incision or lower hemisternotomy incision. The LITA is then sewn directly to the LAD through this limited opening on the beating heart.
The techniques of conventional MIDCAB recently have been refined with the use of robotic technology. The Da Vinci robotic system™ (Intuitive Surgical, Sunnyvale, California) employs fine instruments that simulate the motion of the human wrist (Figure 2). The surgeon controls the instruments at a separate operating console. Hand motions are scaled through a computer interface to eliminate tremor, allowing for precise maneuvers through very small (8 mm) incisions. The surgeon views the operation stereoscopically through the operating console, which allows for real-time three-dimensional vision. With the use of the Da Vinci robotic system, the LITA can be mobilized through three 8 mm ports, avoiding the chest wall trauma associated with open LITA harvesting through a small thoracotomy incision. Likewise, the pericardium may be opened and the LAD identified totally endoscopically prior to making an incision. This allows for a directed small incision over the LAD via either a limited lower hemisternotomy or a limited left anterior thoracotomy, further decreasing surgical tissue trauma.
(Enlarge Image)
(A) The Da Vinci robotic system employs fine instruments, which simulate the motion of the human wrist. The surgeon controls the instruments at a separate operating console. With the use of the Da Vinci robotic system, the left internal thoracic artery (LITA) can be mobilized through three 8 mm ports, avoiding the chest wall trauma associated with open LITA harvesting through a small thoracotomy incision. (B) The surgeon views the operation stereoscopically through the operating console, which allows for real-time three-dimensional vision. Hand motions are scaled through a computer interface to eliminate tremor allowing for precise maneuvers through very small incisions.
Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-LAD territories with MIDCAB using the LITA to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to achieve full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages of the percutaneous treatment of symptomatic coronary stenoses.
Since April 2002, our institution has used HR in selected patients as an alternative to conventional CABG with multivessel coronary artery disease (CAD) involving the LAD. We investigated whether HR was a valid alternative to conventional CABG in patients with multivessel CAD. As a quality assurance project, we present in this paper our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.
Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-left anterior descending (LAD) territories with minimally invasive direct coronary artery bypass (MIDCAB) using the left internal thoracic artery (LITA) to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to perform full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages associated with the percutaneous treatment of symptomatic coronary stenoses. We investigated whether HR was a valid alternative to conventional coronary artery bypass graft surgery in patients with multivessel coronary artery disease. We also present our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.
Minimally invasive direct coronary artery bypass (MIDCAB) has been successfully used to treat isolated lesions of the left anterior descending (LAD) artery by operating on the beating heart without cardiopulmonary bypass (CPB) with excellent medium-term results. MIDCAB involves open harvesting of the left internal thoracic artery (LITA) through a small left anterior thoracotomy incision or lower hemisternotomy incision (Figure 1). The LITA is then sewn directly to the LAD on the beating heart through this limited opening. MIDCAB has been associated with improved cosmetic results and quicker recovery time when compared with traditional sternotomy. Likewise, the avoidance of CPB spares the patient the risks associated with activation of the complement, coagulation and fibrinolysis systems and alterations in red blood cells, leukocytes and platelets, which may result in bleeding and thromboembolic complications, such as stroke. MIDCAB is also associated with a lower cost than coronary artery bypass grafting (CABG). It may be the preferred choice of surgical revascularization in elderly, comorbid and reoperated patients with type B or C lesions.
(Enlarge Image)
Minimally invasive direct coronary artery bypass (MIDCAB) involves open harvesting of the left internal thoracic artery (LITA) though a small left anterior thoracotomy incision or lower hemisternotomy incision. The LITA is then sewn directly to the LAD through this limited opening on the beating heart.
The techniques of conventional MIDCAB recently have been refined with the use of robotic technology. The Da Vinci robotic system™ (Intuitive Surgical, Sunnyvale, California) employs fine instruments that simulate the motion of the human wrist (Figure 2). The surgeon controls the instruments at a separate operating console. Hand motions are scaled through a computer interface to eliminate tremor, allowing for precise maneuvers through very small (8 mm) incisions. The surgeon views the operation stereoscopically through the operating console, which allows for real-time three-dimensional vision. With the use of the Da Vinci robotic system, the LITA can be mobilized through three 8 mm ports, avoiding the chest wall trauma associated with open LITA harvesting through a small thoracotomy incision. Likewise, the pericardium may be opened and the LAD identified totally endoscopically prior to making an incision. This allows for a directed small incision over the LAD via either a limited lower hemisternotomy or a limited left anterior thoracotomy, further decreasing surgical tissue trauma.
(Enlarge Image)
(A) The Da Vinci robotic system employs fine instruments, which simulate the motion of the human wrist. The surgeon controls the instruments at a separate operating console. With the use of the Da Vinci robotic system, the left internal thoracic artery (LITA) can be mobilized through three 8 mm ports, avoiding the chest wall trauma associated with open LITA harvesting through a small thoracotomy incision. (B) The surgeon views the operation stereoscopically through the operating console, which allows for real-time three-dimensional vision. Hand motions are scaled through a computer interface to eliminate tremor allowing for precise maneuvers through very small incisions.
Hybrid revascularization (HR) combines staged percutaneous coronary intervention (PCI) on stenoses in the non-LAD territories with MIDCAB using the LITA to the LAD. The LITA-to-LAD graft, which has a 5-year patency rate of 95%, is the major determinant of the long-term survival for patients. Thus, HR aims to achieve full revascularization without compromising the survival advantage of the LITA-to-LAD graft, while preserving the minimally invasive advantages of the percutaneous treatment of symptomatic coronary stenoses.
Since April 2002, our institution has used HR in selected patients as an alternative to conventional CABG with multivessel coronary artery disease (CAD) involving the LAD. We investigated whether HR was a valid alternative to conventional CABG in patients with multivessel CAD. As a quality assurance project, we present in this paper our early experiences with HR using a combined approach of advanced PCI and robotically-assisted MIDCAB.
