Repeat Revascularization after Minimally Invasive Coronary Artery Bypass Grafting

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy is a novel technique for coronary revascularization that is increasingly used around the world. However, multivessel MICS CABG is difficult, and concerns about repeat revascularization (RR) have been raised. This longitudinal study describes the rates of RR among patients who have undergone MICS CABG and identifies targets for improvement. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> A prospective observational study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting was performed through a small left thoracotomy, using the in situ left internal mammary artery, ± a radial artery, and 1 to 3 saphenous veins anastomosed proximally to the aorta. Patients were followed annually. We examined the difference between the first half and second half of the series to ascertain the effects of a learning curve. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Eighty percent of the procedures were performed off-pump. The median number of grafts performed were 2, and the left anterior descending, diagonals, obtuse marginals, and posterior interventricular artery were the distal targets in 94%, 12%, 44%, and 26%, respectively. The graftability index (#grafts/#diseased vessels) was 0.93. Revascularization of targets smaller than 1.5 mm decreased from 69% to 50% ( P = 0.002) between the series’ first and second halves. Overall, RR was needed in 21 patients (6.9%) and was performed at a mean ± SD of 1.7 ± 1.6 years postoperatively. The culprit lesion was attributed to the index surgical procedure (“graft-associated”) in 52%, to a stent stenosis or progression of native disease in 43%, and was unidentified in 5%. Patients with graft-associated RR had a lower graftability index at operation (0.73 vs 0.94) and more frequent involvement of the circumflex system (0.8 vs 0.3). The overall rate of RR at 3 years decreased from 11% in the first half to 2.6% in the second half ( P = 0.001). </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> The need for RR is part of the learning curve with MICS CABG, involves a graft in half of the cases, is more common in patients who had a lower graftability index at operation, and markedly improves with experience. </jats:p></jats:sec>

Minimally invasive single‐vessel left internal mammary to left anterior descending artery bypass grafting improves outcomes over conventional sternotomy: A single‐institution retrospective cohort study

“…As noted by Rodriquez et al, need for repeat revascularization usually presents in later follow‐up. In the 6.9% of patients, they observed the need to repeat revascularization, presentation occurred at an average follow up of 1.7 ± 1.6 years and in 52% of these patients was attributed to the index surgical procedure . Despite this, the available data from Ruel et al and Holzhey et al demonstrates a promising overall angiographic patency of 92 to 94.3% with a 100% patency of LIMA bypass grafts at 6‐month follow‐up in MICABG patients and a corresponding 5‐ and 7‐year Kaplan‐Meier survival of 91.9% and 89.4%, respectively.…”

Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study

“…Even after such correction, however, MACCE incidence rates were comparable between the MICS and CABG patient groups. While there have been prior controversies regarding the ability of MICS to achieve total revascularization (20), in our center MICS was able to achieve this operative outcome when performed through a small left fourth and fifth intercostal incision.…”

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

“… 22 Rodriguez et al have examined rates of reoperation in 306 patients who underwent MICS CABG procedure where 7% received repeat revascularization at 1.7 ± 1.6 years postoperatively with the rate decreasing from 11% in the first half of the series to 2% for the latter half. 30 …”

“…22 Rodriguez et al have examined rates of reoperation in 306 patients who underwent MICS CABG procedure where 7% received repeat revascularization at 1.7 ± 1.6 years postoperatively with the rate decreasing from 11% in the first half of the series to 2% for the latter half. 30 The STET trial showed a 10% increased hospital cost with MICS CABG versus OPCAB (£5,079 vs £4,566), which included £869 of reoperation cost for 4 patients in the MICS CABG group versus £0 in the OPCAB group. 25 The addition of a robot in the LIMA takedown changes the cost of the approach and Pasrija et al have shown that a robot-assisted (RA) MIDCAB is less costly in comparison to a totally endoscopic coronary artery bypass (TECAB; $22,679 vs $33,769).…”