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How to Perform a MIDCAB Procedure Step-by-Step in Single Vessel Disease

Article · July 2018

DOI: 10.25373/ctsnet.6713054.

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Germán Fortunato Vadim Kotowicz

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Ricardo Posatini Roberto Rafael Battellini

Hospital Italiano de Buenos Aires Hospital Italiano de Buenos Aires
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How to Perform a MIDCAB Procedure Step-by-Step
in a Single Vessel Disease and How do We Do It

Authors: Germán Alberto Fortunato, MD; Ricardo Posatini, MD; Roberto
Battellini, MD; Vadim Kotowicz, MD.

Department of Cardiovascular Surgery, Hospital Italiano de Buenos Aires,
Buenos Aires, Argentina.

CASE REPORT

Introduction

Since the first reports of the off-pump technique and by a minimally

invasive access (1-2), coronary surgery procedure performed through a
small anterior lateral thoracotomy without cardiopulmonary bypass has
become an increasingly popular technique worldwide. The minimally
invasive direct coronary artery bypass (MIDCAB) has been used for
patients with a single-vessel disease when a coronary stent placement
failed. In this step-by-step video, the authors show how they do it.

Case Presentation

A 73-year-old female patient with severe chest pain is brought to the

Emergency room. In the ECG there was no ST elevation, and the cardiac
enzymes were normal. A catheterization was performed on the coronary
arteries and a 100% stenosis of de Left Descending Artery (LDA) was
observed. Due to the impossibility of stent placement, a surgical solution
was decided. Through a left anterior small thoracotomy (video-assisted), a
single bypass from the Left internal mammary artery (LIMA) to LDA was
performed with a good postoperative outcome.

Operative Technique

1. A small anterior thoracotomy was performed in the left fifth

intercostal space. TEE and ECG were used to monitor ventricular
function during the whole procedure.

2. A special rib retractor (Thoragate™, GEISTER®. Germany) was

selected to elevate the fifth rib for improved visualization for LIMA
harvesting. It is not mandatory but, in some cases, a video camera could
be helpful for a better harvesting technique.

3. Its important to mobilize the artery as high as possible to ensure an

adequate length to reach the coronary artery without tension.

4. The pericardium was opened. A silk suture could be used for

traction of the pericardium.

5. The anterior descending artery was identified.

6. A stabilization device was positioned to expose the descending

artery.

7. A longitudinal incision was made in the coronary artery and bleeding

was controlled with carbon dioxide.

8. A 1.2 mm shunt was inserted into the coronary artery.

9. LIMA was prepared for bypass. Continuous stitches of 7.0

polypropylene (PROLENE® Ethicon) were used to construct an end-to-
side anastomosis from the LIMA to LAD.
 10. The shunt was removed and the anastomosis was finished.

11. Remotion of bulldog clamp from the LIMA.

12. TEE and ECG showed no complications during the entire procedure.

Discussion

A small thoracotomy instead the classical sternotomy could reduce

notoriously thorax trauma. Shorter hospital stay, less postoperative pain,
and faster recovery to activities have been described by some authors that
compared CABG versus MIDCAB and described this last one as a feasible
technique. (3-5) Nonetheless, a minimally invasive thoracotomy
represents a very different approach when compared to sternotomy
because the operative field is external, the anatomical relationships are
different, and with a small approach, the structures are difficult to observe
and control. Another disadvantage is that, while dissecting the mammary
artery, sometimes direct vision may not be enough, so a video camera can
be very useful for reach 5 to 8 cm more of this artery. A short pedicle,
associated with pulmonary excursion and intimate contact with the
endothoracic fascia, may cause an early bypass occlusion. (6) In addition,
the potential benefits of MIDCAB, the low incidence of bleeding, early
mobilization and aesthetic results may be only weak factors that promote
the adoption of this technique. We argue that today's development is
supported by factors that are not based on evidence, such as increased
demand from patients and referring physicians.(7)

Conclusions

The MIDCAB technique through a left anterior small thoracotomy it is an

 excellent choice when a single coronary vessel is affected.

References

(1) Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial
revascularisation without extracorporeal circulation. Experience in 700
patients. Chest 1991;100:312±316.

(2) Subramanian VA, Sani G, Benetti FJ, Cala®ore AM. Minimally
invasive coronary bypass surgery: a multicentre report of preliminary
clinical experience. Circulation 1995;92(Suppl 1):645 (abstract).

(3) Detter C, Reichenspurner H, Boehm DH, et al. Minimally invasive direct
coronary artery bypass grafting (MIDCAB) and off-pump coronary artery
bypass grafting (OPCAB), two techniques for beating heart surgery. Heart
Surg Forum. 2002; 5:157–162. [PubMed: 12114131].

(4) Greenspun HG, Adourian UA, Fonger JD, Fan JS. Minimally invasive
direct coronary artery bypass (MIDCAB), surgical techniques and
anesthetic considerations. J Cardiothorac VascAnesth. 1996; 10:507–509.
[PubMed: 8776646].

(5) Iribarne A, Easterwood R, Chan E, et al. The golden age of minimally

invasive cardiothoracic surgery: current and future perspectives. Future
Cardiol. 2011 May; 7(3): 333–346. doi: 10.2217/fca.11.23.

(6) Battellini R. Minimally Invasive Coronary Surgery (phd thesis).

Herzzentrum Leipzig, and Cardiovascular Surgery Department Hospital
Privado de Comunidad de Mar del Plata. (2001).
(7) Fortunato GA, Rios M, Battellini R, et al. Is Minimally Invasive Mitral
Valve Surgey Possible in Complex Patients? Rev Argent Cadiol
2017;85:314-319. http://dx.doi.org/10.7775/rac.v85.i4.10396.

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