Benetti Foundation, Rosario, Argentina.
Invita Science Corp, Port St. Lucie, FL, USA.
Surg Technol Int. 2021 May 20;38:290-293. doi: 10.52198/21.STI.38.CV1400.
We describe how to perform left internal mammary artery (LIMA) bypass to the left anterior descending (LAD) artery, the so-called MINI Off-pump Coronary Artery Bypass (MINI OPCAB).
We included patients with a demonstrated predominant ischemia related to the LAD territory. Of 70 patients who were operated upon at the Benetti Foundation, 10 received hybrid revascularization.
The patient is prepared as for a standard coronary bypass operation through sternotomy. The sternum is opened to the 3rd or 4th intercostal space depending on the anatomy, and a retractor is put in place. The left mammary artery is generally dissected to about 8 cm and isolated without the veins. Importantly, the angle of the superior part, where the mammary artery is attached to the sternum, needs to be below 20% to avoid any potential kinking. The pericardium is cleaned to identify the area of the pulmonary artery. The pericardium is opened to the apex and towards the right to around 5 to 6 cm initially. In most cases, the area of the LAD can be seen and the potential area of the anastomosis is defined. The patient is heparinized and the LAD is occluded with 5-0 Proline. A mechanical stabilizer is put in place and the anastomosis is performed. When the bypass is finished, and before sutures are tied, the stitches of 5-0 polypropylene around the artery are released, along with the clamp of the mammary artery; the anastomosis is then tied. The mechanical stabilizer is removed, the stitches of the pericardium are released and the flow of the graft is measured, while ensuring that there is no kinking. If the flow and Pulsatility and Resistance (PR) are acceptable, the mammary is fixed with 2 stitches of 7-0 polypropylene on both sides around 1 cm from the anastomosis. The heparin is reverted with protamine and a drain is put in place, while taking care to avoid any chance of touching the mammary artery or the anastomosis. The sternum is closed with 1 or 2 wires.
Operative mortality in this series was 0%; one patient was converted to sternotomy off-pump (1.4%). None of the grafts were revised after measurement with a Medistim system (Medistim ASA, Oslo, Norway). Fifty five patients (79%) were extubated in the operating room The average hospitalization stay was 60 hours (SD 17, 95% CI). Sixteen patients who underwent the LIMA-to-LAD procedure were restudied, with 100% patency. At 144 months, 82% of the patients were alive and 68% were asymptomatic.
Additional clinical experience is required to be able to reproduce this operation on a large scale and expand the MINI OPCAB operation in hybrid revascularization.
我们介绍了如何进行左内乳动脉（LIMA）到左前降支（LAD）的旁路手术，即所谓的MINI 非体外循环冠状动脉旁路移植术（MINI OPCAB）。
我们纳入了那些存在与 LAD 区域相关的显著缺血的患者。在贝内蒂基金会接受手术的 70 名患者中，有 10 名接受了杂交血运重建。
患者通过胸骨切开术准备进行标准的冠状动脉旁路手术。胸骨根据解剖结构打开至第 3 或第 4 肋间隙，放置牵开器。通常将左乳内动脉解剖至约 8cm 并分离，不包括静脉。重要的是，乳内动脉与胸骨相连的上部分的角度需要低于 20%，以避免任何潜在的扭曲。清理心包以识别肺动脉区域。心包切开至心尖并向右侧约 5 至 6cm 初始。在大多数情况下，可以看到 LAD 区域，并定义潜在的吻合部位。患者接受肝素化，用 5-0 Proline 闭塞 LAD。放置机械稳定器并进行吻合。旁路完成后，在打结缝线之前，松开动脉周围 5-0 聚丙稀缝线的缝线，同时松开乳内动脉的夹具；然后进行吻合。移除机械稳定器，松开心包缝线并测量移植物的流量，同时确保没有扭曲。如果流量和搏动性和阻力（PR）可接受，则在吻合口两侧约 1cm 处用 2 个 7-0 聚丙稀缝线固定乳内动脉。用鱼精蛋白逆转肝素，并放置引流管，同时注意避免任何触碰乳内动脉或吻合口的机会。胸骨用 1 或 2 根线闭合。
本系列手术死亡率为 0%；1 例患者转为非体外循环开胸（1.4%）。在使用 Medistim 系统（Medistim ASA，挪威奥斯陆）测量后，没有一个移植物需要修改。55 名患者（79%）在手术室拔管。平均住院时间为 60 小时（SD 17，95%CI）。16 名接受 LIMA 至 LAD 手术的患者进行了复查，均为通畅。144 个月时，82%的患者存活，68%无症状。
需要更多的临床经验才能在大规模复制这种手术，并在杂交血运重建中扩展 MINI OPCAB 手术。
