Minimally invasive surgical coronary artery revascularization—how to initiate a safe and sustainable program

Introduction

Background

Minimally invasive coronary artery bypass grafting (MI-CABG) approaches that comply with the principles of traditional CABG are rapidly evolving with reported prognostic, quality of life, internal thoracic artery (ITA) graft patency, and patient satisfaction outcomes that are comparable with conventional CABG by sternotomy access (1-8). Recent reports reconfirm the superiority of CABG over percutaneous coronary interventions (PCIs) in various clinical scenarios (9-23) and resulted in renewed interest in minimally invasive surgical revascularization strategies (24-29). Harvesting of the left or bilateral ITA and the subsequent anastomosis to the left anterior descending (LAD) coronary artery and other target vessels under direct vision (30-32) or by using modern endoscopic (33,34) or robotic technology (35-43), with or without the use of cardiopulmonary bypass (CPB), are regarded as the fundamental components of contemporary MI-CABG strategies.

Rationale and knowledge gap

Experienced MI-CABG centres report excellent perioperative, long-term quality of life, and prognostic outcomes (44,45). However, the safe introduction of new MI-CABG programs are potentially deterred by various factors (46-54) that include extensive infrastructure planning, new surgical skill development, implementation of risk management strategies and the mastering of challenging learning curves in an era of decreasing surgical revascularization volume, increased patient expectations, increasing healthcare costs and strict clinical governance (55-60).

Objective

This manuscript provides an overview of contemporary MI-CABG technology and systematically outlines the fundamental aspects of MI-CABG infrastructure design and implementation, current operative approaches and procedural principles, initial patient selection and important risk aversion strategies with the intention of assisting upcoming MI-CABG centres to establish and maintain safe and sustainable programs in both developed and developing countries.

Current minimally invasive surgical coronary revascularization technology

The renewed interest in MI-CABG resulted in exciting advances in less invasive thoracic retractor, three-dimensional (3D) videoscopic/endoscopic, and new generation robotic technology that facilitate direct vision-minimally invasive direct coronary artery bypass (DV-MIDCAB), videoscopic assisted-MIDCAB (VA-MIDCAB), robotic assisted-MIDCAB (RA-MIDCAB), and total endoscopic coronary artery bypass (TECAB) techniques. These technological developments are paralleled by improved target vessel stabilizer, peripheral CPB, and other equipment designs that enable safe and efficient ITA harvesting, excellent coronary artery target vessel access and exposure, operative field stabilization, and anastomotic constructions.

Direct vision retractor, videoscopic, and robotic systems

The ThoraTrak^TM retractor system (Medtronic, Minneapolis, MN, USA) used in conjunction with the Rultract^TM Skyhook retractor system (Rultract Inc., Cleveland, OH, USA) and iron assistant (Geister, Tuttlingen, Germany), as well as the Takahasi^TM retractor system (Delacroix-Chevalier, Paris, France) are amongst the systems used in DV-MIDCAB to harvest the ITA, perform proximal aorta- and multi-vessel distal coronary artery anastomosis (Figure 1A-1D). The EndoEye Flex HD^TM (Olympus, Tokyo, Japan) and the EndoCAMeleon^TM videoscopic systems (Karl Storz, Tuttlingen, Germany) are amongst the videoscopic systems available for VA-MIDCAB in combination with special long-shafted endoscopic instruments. The Da Vinci^TM robotic system (Intuitive, Sunnivale, CA, USA), which consists of a surgical console (Figure 2A) that provide 3D, high-definition videoscopic imaging to manipulate micro-instruments on the patient cart (Figure 2B) through a master controller (Figure 2C) is currently the most widely used robotic system in RA-MIDCAB and TECAB. Other recently introduced robotic systems, each with its own unique design and operational benefits, are progressively being introduced and include the Hugo^TM (Medtronic, Minneapolis, MN, USA) and Versius^TM (CMR, Cambridge, UK) robotic systems.

Figure 1 Current retractors used in minimally invasive coronary artery revascularization under direct vision include (A) the ThoraTrak^TM system (Medtronic, Minneapolis, MN, USA), which is used in conjunction with (B) the Rultract^TM Skyhook (Rultract Inc., Cleveland, OH, USA) for (C) internal mammary artery harvesting and proximal aorta access. (D) The Takahashi^TM MIDCAB retractor system (Delacroix-Chevalier, Paris, France) provides access and visualization for complete surgical revascularization under direct vision. The use of these images was approved by the manufacturers. MIDCAB, minimally invasive direct coronary artery bypass.

Figure 2 The Da Vinci robotic system (Intuitive, Sunnivale, CA, USA) is currently the most widely used robotic system in cardiac surgery and consists of (A) a surgical console that provide 3D high-definition videoscopic imaging to manipulate micro-instruments by (B) the patient cart through (C) a master controller with precision, increased dexterity, and control. These images were obtained from an open access source (https://www.intuitive.com/en-us/products-and-services/da-vinci/systems). 3D, three-dimensional.

Target vessel stabilizers, intra-coronary shunts, and visualization accessories

Target vessel suction stabilizers used in off-pump MI-CABG (Figure 3A,3B) include the Octopus Nuvo^TM tissue stabilizer (Medtronic, Minneapolis, MN, USA) used in conjunction with the Starfish NS^TM heart positioner (Medtronic, Minneapolis, MN, USA), the Genzyme-OPCAB elite system (Genzyme, Boston, MA, USA) and Axius^TM-Xpose^TM Stabilizer and Apical Positioning Device (Guidant Corporation Cardiac Surgery Group, Indianapolis, IN, USA), while low-profile compressive operative field stabilizers (Figure 3C) include the Terumo Stablesoft II stabilizer (Terumo, Tokyo, Japan). Various intra-coronary shunt designs, which maintain distal perfusion during anastomosis (61) are available and include the Clear View^TM (Medtronic, Minneapolis, MN, USA), Axius^TM coronary shunt (Guidant Corporation Cardiac Surgery Group, Indianapolis, IN, USA), and Nautica^TM (Meril Corporation, Gujurat, India) systems (Figure 3D). Blood-clearing carbon dioxide (CO₂) mist-blower devices (Figure 3E) contribute to creating a bloodless operative field and include amongst other the Accumist Blower^TM (Medtronic, Minneapolis, MN, USA).

Figure 3 Current target vessel stabilizers, intra-coronary shunts and visualization accessories for beating heart minimally invasive coronary artery revascularization include amongst others, (A) the Octopus Nuvo^TM suction tissue stabilizer (Medtronic, Minneapolis, MN, USA), (B) the Starfish NS^TM heart positioner (Medtronic, Minneapolis, MN, USA), (C) the low-profile compressive Terumo Stablesoft II stabilizer (Terumo, Tokyo, Japan), (D) intra-coronary shunts and (E) blood-clearing CO₂ mist-blower device (Accumist Blower, Medtronic, Minneapolis, MN, USA). The use of these images was approved by the manufacturers. CO₂, carbon dioxide.

Peripheral CPB and less invasive cardioplegia delivery technology

The ThruPort^TM System (Edwards Lifesciences, Irvine, CA, USA) was originally designed for MI-CABG (62) and consists of an endo-aortic balloon occlusion device that facilitates antegrade cardioplegia delivery, aortic root venting and pressure monitoring, a femoral arterial cannula, femoral venous cannula, a pulmonary catheter vent and a peripheral retrograde cardioplegia catheter. Safe and effective MI-CABG are now commonly performed using peripheral CPB and external aortic clamping with separate antegrade cardioplegia delivery and aortic root venting (63,64).

Automated robotic anastomotic, manual suture knot tying, and conduit flow assessment devices

The C-Port Flex-A^TM automated anastomotic device (Aesculap, Center Valley, PA, USA) was previously used in TECAB to construct coronary anastomosis with an interrupted row of 13 microscopic stainless steel staples. The extensive cost and lack of clinical and industry support resulted in its unfortunate recent termination, but it remains the only Food and Drug Administration (FDA) approved automated coronary anastomosis device at present (35,39,65,66). The S² Distal^TM Anastomotic System (iiTech Technology Solutions, Pittsburg, PA, USA) and the ELANA^TM system (AMT Medical, Rosemont, IL, USA) are innovative devices currently under investigation as alternative automated anastomotic technology for TECAB. The Cor-Knot^TM mini-suture knotting device (LSI solutions, New York, NY, USA) can be used as an alternative to manual suture knotting (Figure 4A) of MI-CABG anastomosis (67). The value of documenting transit time flow measurements as an indicator of conduit-target vessel patency is well reported (68) and include the MiraQ^TM system (Medistim, Oslo, Norway), which integrates ultrasound imaging and flow measurement data derived from ultrasound flow probes (Figure 4B,4C).

Figure 4 Contemporary suture knot tying and conduit flow assessment devices. (A) The Cor-Knot^TM mini-suture knotting device (LSI solutions, New York, NY, USA) can be used as an alternative to manual suture knotting. Transit time flow measurement systems (B) integrate ultrasound imaging and flow measurement data derived from ultrasound flow probes (C) as an indicator of conduit-target vessel patency and include the MiraQ^TM system (Medistim, Oslo, Norway). The use of these images was approved by the manufacturers.

Infrastructure design and implementation

The introduction of any new surgical procedure requires extensive collaboration between institutional management, quality control, clinical governance, industry, healthcare funder, and clinical teams. The proposal of initiating a state-of-the-art MI-CABG program will be scrutinized and compared against the available clinical outcome data, patient satisfaction, and cost-effectiveness reports for conventional CABG (69-72).

MI-CABG healthcare economics

Contemporary MI-CABG industry role-players provide negotiable rental, leasing, and purchase options for upcoming and established centres. The acquisition and maintenance costs of DV-MIDCAB retractors are substantially less than endoscopic and robotic systems and may be more applicable in developing countries where healthcare cost constraints are challenging. By providing a multi-disciplinary cost-benefit analysis that outlines the return on investment with high-volume use and full occupation of available theatre time, investment in endoscopic or robotic systems may be justified. Arom (69), Leyvi (70), and Pasrija (71) independently reported that MI-CABG procedural costs are offset by reduced post-operative costs, rapid rehabilitation and low readmission rates. Pasrija and colleagues (71) also confirmed that RA-MIDCAB does not increase index hospitalization costs when compared to conventional CABG unless combined with PCI as part of planned hybrid revascularization during the same admission. The significant operational costs of TECAB, which include automated suture devices and other costly consumables, limit its application to expert centres in developed countries.

Hybrid operative theatre design

DV-MIDCAB and VA-MIDCAB can be performed in a standard cardiac surgical operating theatre, whereas RA-MIDCAB and TECAB usually require a spacious and dedicated robotic theatre that can facilitate multi-disciplinary use. Modern hybrid cardiovascular operating rooms (Figure 5) are designed to provide an efficient workflow, safe working environment, and unobstructed access to contemporary surgical and transcatheter equipment. Modern MI-CABG operative room design require sufficient ergonomics layouts to accommodate 2 cardiac anaesthetists and ventilator systems, transoesophageal echocardiography (TEE), 2 perfusion technologists and a CPB machine, an endoscopic camera or robotic surgical system, CO₂ delivery stack, various unobstructed synchronised monitoring screens, integrated image projection, 2 surgeons, a theatre nurse and a supporting nurse with easy access to all routine cardiovascular equipment, guidewires, grafts, stents, and sutures. Various reports from the United States and Asia suggest a complete return on investment within 2 years of establishing a hybrid theatre (72).

Figure 5 Modern hybrid cardiovascular operative room design.

Teamwork, communication, ownership, and leadership

To promote trust and effective teamwork, established centres suggest that a consistent MI-CABG team commit to ongoing training, education, and successful execution of at least the first 20 procedures in close collaboration and partnership with expert centres (45,46,50-52). All team members should be familiar with the theatre and equipment layout, each procedural step, the signs suggestive of ischemia or electrocardiographic changes and how to efficiently manage adverse events. Frequent constructive post-training and postoperative team debriefing sessions that focus on continuous improvement strategies are invaluable and reinforces ownership of each team member under surgical leadership. Effective intraoperative communication is essential and any concerns should be communicated, respected, and immediately addressed. Communication during RA-MIDCAB and TECAB procedures can be enhanced by Bluetooth^TM headsets and microphones. As the surgeon is isolated from the operative field in RA-MIDCAB and TECAB, potential complication protocols and emergency sternotomy conversions (SC) should be well practised. Skilled intensive care, ward, and outpatient nurses, physiotherapists, other allied health care professionals, the patient’s family and referring physicians form part of an extended post-operative MI-CABG team to ensure continuity of post-operative care (45,50).

Training and education

Industry and expert centres propose a stepwise transition towards MI-CABG by acquiring proven proficiency and competency in multi-vessel complex on-pump CABG by sternotomy access (73), followed by a safe transition to multi-vessel complex off-pump (74) or peripheral CPB assisted CABG, subsequent progression to single vessel MI-CABG and finally multi-vessel peripheral CPB assisted, on-pump, or off-pump MI-CABG with its variations (50,51). Extensive MI-CABG training and education will usually be supervised and supported by industry to ensure that the upcoming team is comfortable, safe, and well-skilled, preferably in partnerships with expert centres (51,52,75). Teams who wish to introduce DV-MIDCAB in their practice need to be well acquainted with the technical aspects and setup of the available retractor systems, whereas VA-MIDCAB programs require training in the use of endoscopic stacks and long shaft instruments. RA-MIDCAB and TECAB programs require extensive training in robotic system setup, docking, draping, instrument exchanges, undocking, console efficiency (Figure 6A) and emergency scenario protocols in compliance with strict industry rules and regulation for accreditation. A combination of online training platforms and high-fidelity drylab, cadaveric wetlab, and animal simulations (76-78) should be utilised for mastering operative field ergonomics (Figure 6B), ITA harvesting, target vessel exposure (Figure 6C), arteriotomy preparation, intra-coronary shunt insertion, a variety of coronary anastomosis techniques (79,80), and training in peripheral CPB techniques (81).

Figure 6 Minimally invasive surgical coronary artery revascularization training include (A) familiarity with retractor and robotic systems, (B) high-fidelity drylab procedural training and the mastering of (C) operative field ergonomics. All images used were either original or approved by the manufacturers.

Initial patient selection

Expert centres suggest that high-risk clinical, target vessel, vascular, and echocardiographic characteristics, which are outlined in Table 1, should preferably be excluded during the initial introduction of MI-CABG programs into surgical practices (50). Evaluation of the aorta-iliac-femoral arterial-axis by contrasted computerized tomography (CT), magnetic resonance imaging or an additional peripheral contrast injection during coronary angiography is mandatory if peripheral CPB is considered (50). Safe VA-MIDCAB, RA-MIDCAB, and TECAB instrument manoeuvrability can be predicted by CT-scan measured distances between the chest wall and pericardium being more than 1.7 cm, the distance between the chest wall and LAD being more than 1.5 cm and the antero-posterior to transverse distance thoracic ratio measuring more than 0.45 (45,50).

Current MI-CABG approaches, operative principles, and risk aversion strategies

The procedural conduct and technical aspects of DV-MIDCAB, VA-MIDCAB, RA-MIDCAB, and TECAB, with or without the use of peripheral CPB and cardioplegic arrest are well described (30,43,80) and share various common principles.

General patient positioning and setup

Following routine cardiac anaesthesia, MI-CABG patients are positioned supine, with the left hemithorax elevated by an inflatable cushion and the left arm flexed. External defibrillation pads are routinely applied and positioned away from the surgical field, while surgical draping allow immediate full sternotomy and peripheral vascular access (45,50). Single-lung ventilation by double-lumen tube or bronchial blockers is advocated and SC is recommended if lung isolation is inadequate (50). The relevant retractor systems are then assembled in DV-MIDCAB, while the endoscopic or robotic systems used in VA-MIDCAB, RA-MIDCAB, and TECAB are adequately positioned and prepared for installation. If peripheral CPB by femoral access is planned, a right internal jugular venous cannula can be utilized for additional peripheral venous drainage in conjunction with or as an alternative to vacuum assisted drainage (50).

Incisions and port placement

DV-MIDCAB is routinely performed through a left 4–6 cm antero-lateral sub-mammary incision that facilitates intra-thoracic access through the 3^rd or 4^th intercostal space, after which the relevant retractor blades (Figure 7A) are selected and positioned to allow visualization of the left ITA (30-32). If the ThoraTrak^TM, Rultract^TM Skyhook, and iron assistant systems are used, installation include the placement of the relevant blade into the antero-lateral incision with the tip of the blade extending up to the second rib. The Rultract^TM can be swivelled superiorly to gain access to the aorta if needed. A 2 cm sub-xyphoid and 6^th intercostal anterior axillary incision facilitates the introduction of stabilizer devices once the ITA is harvested. The Takahashi^TM MIDCAB retractor system follow the same principles (63,64). VA-MIDCAB (33,34) utilises a 4–6 cm sub-mammary incision as working port in the 4^th intercostal space, which is independent from a 1 cm camera port, 5 mm grasper port and 5 mm harmonic scalpel port in the 4^th intercostal anterior, 3^rd intercostal posterior, and 6^th intercostal posterior axillary line, which are used for ITA harvesting (Figure 7B). RA-MIDCAB (35,36,50) and TECAB (37-43) commonly utilise 3 or 4 incisions (Figure 7C) that include 1.0 cm anterior-axillary instrument ports in the 2^nd and 6^th intercostal spaces and a 1.0-cm camera port in the 4^th anterior axillar intercostal space, which will be extended 3–4 cm following ITA harvesting to function as a non-rib-spreading working port in RA-MIDCAB. All ports should be introduced first by blunt dissection after single-lung ventilation is established to determine the presence and extent of lung adhesions, which can carefully be manually dissected from the anterior and lateral chest well to provide sufficient instrument port insertion space and visualization of the ITA. After RA-MIDCAB and TECAB port placement are completed, the surgical table is lowered, rotated 10-degree towards the right and the robotic system subsequently docked (Figure 7D). The surgeon then moves to the console, while a surgical assistant resumes the role of instrument exchanger and other tasks as required. Continuous warm humidified CO₂ insufflation at pressures of 8–12 mm of mercury expands the operative field and intra-thoracic workspace without compromising hemodynamic stability and can be decompressed by the insertion of a Veress needle (Endomed Systems, Ravensburg, Germany) through the chest wall.

Figure 7 Incisions and port placements utilised in (A) direct visual, (B) videoscopic, and (C) robotic minimally invasive surgical coronary artery revascularization, with (D) installation and docking of the robotic system. All images used were either original or approved by the manufacturers.

ITA harvesting, conduit preparation, and proximal aorta anastomosis manoeuvres

Harvesting of the ITA in MI-CABG follows routine CABG principles. The ITA is carefully dissected from the anterior chest wall in its entire length, either as an in-situ pedicle or as a skeletonized conduit, where the latter is reported to provide additional length, increase flow capacity, easier intrathoracic manoeuvrability, effortless automated-device anastomosis, and more accurate transit-time Doppler flow measurements (68). Low-power diathermy and fine tip instruments are used to avoid side-branch metallic clip contact, excessive traction, grasping, and manipulation. Correct ITA orientation is confirmed before exteriorization and topical and intra-ITA vasodilator therapy are often used as required. The left and right ITA are anatomically close to each other compared to open sternotomy access. In DV-MIDCAB, the left ITA is harvested under direct vision, of which the distal portion is often identified during the initial mini-thoracotomy incision (Figure 8A). As the right ITA is not easily accessible, saphenous vein, or radial artery conduits are commonly used in conjunction with the left ITA and are usually anastomosed to the proximal aorta by various retractor and stabilizer specific manoeuvres that include pericardial traction sutures up to level of the aorta, freeing peri-aortic fat, pushing the pulmonary artery inferiorly and posteriorly and subsequent completion of the proximal anastomosis using a side biting clamp and other routine CABG instruments (Figure 8B). For VA-MIDCAB, long-shafted instruments and diathermy are used to identify the ITA, to dissect the medial and lateral endothoracic facia and to divide ITA branches by combination of diathermy and appropriately sized endothoracic clips (Figure 8C). RA-MIDCAB and TECAB utilize low-power diathermy and robotic clip applicators for full length ITA dissection and branch ligation (Figure 8D). If only a single ITA is harvested, division can be performed after systemic heparinization and haemostasis are ensured. If bilateral ITA conduits are used in VA-MIDCAB, RA-MIDCAB, and TECAB, the right ITA is harvested first, using the same left hemithorax port incisions and ITA harvesting principles as described. A 0-degree robotic endoscope can assist with initial right ITA visualization, dissection of the substernal anterior mediastinal fibro-fatty tissue and right pleural space entrance, after which it is then exchanged with a 30-degree for the remained of the right ITA harvesting (35). The Endo-Wrist^TM stabilizer, which is inserted through a 12 mm subcostal 4^th robotic port between the mid-clavicular line and xyphoid process in RA-MIDCAB and TECAB, can compress the anterior mediastinal fat and cardiac border to provide access to the proximal first intercostal branch and distal ITA segment respectively (41). Once the right ITA is harvested, the left ITA is dissected, with neither ITAs divided until coronary target vessels are exposed and prepared. The right ITA is then tunnelled through the anterior mediastinum following systemic heparinization or transsected as a free graft. The videoscopic or robotic systems are subsequently retracted from the operative field in all approaches except for TECAB, after which preparation of the distal ITA is performed through the working port in DV-MIDCAB, VA-MIDCAB, and RA-MIDCAB. Traumatic and atraumatic ITA dysfunction can occur and may warrant SC to ensure satisfactory ITA function and an excellent subsequent prognosis (50).

Figure 8 Minimally invasive access strategies for ITA conduit harvesting and proximal aorta conduit anastomosis. (A) ITA harvesting and (B) proximal aorta conduit anastomosis under direct vision, (C) videoscopic assistance, and by using (D) robotic systems. All images used were either original or approved by the manufacturers. ITA, internal thoracic artery.

Target vessel exposure, stabilization, and anastomosis

In DV-MIDCAB, the appropriate retractor blades are installed to allow wide pericardial incision for increased cardiac mobility, target vessel evaluation, stabilizer device insertion or the placement of traction tapes around the left pulmonary vein and inferior vena cava (63,64). The LAD and target vessels coursing on the inferior and lateral walls are easily accessible through various manoeuvres that position the cardiac apex superior-medially. As the proximal venous conduit-aorta anastomosis are usually performed after ITA harvesting, the sequence of revascularization may deviate from traditional beating heart principles by starting at the posterior descending artery, followed by the obtuse marginal targets and eventually the LAD using standard coronary artery surgery instruments (Figure 9A). For off-pump MI-CABG approaches, the coronary arteriotomy is preceded by a team check of hemodynamic and electrocardiographic stability, which is then followed by proximal snare occlusion (Gore Medical, Tempe, AZ, USA), insertion of an appropriately sized intracoronary shunt and release of the snare. The target vessel anastomosis is then constructed with the additional assistance of a blood-clearing CO₂ mist device. Inadequate target vessel visualization can potentially be optimised by excluding patients with intramuscular target vessel courses and large epicardial fat distributions as identified by coronary angiography and cardiac CT, careful application of suction- or compression-stabilizing devices and using exposure sutures to manipulate target vessel into the surgical view. By directly visualizing the interventricular septum, the LAD and large diagonal branches can be differentiated. The coronary anastomosis in VA-MIDCAB is similarly performed through a separate antero-lateral incision in the 4^th intercostal space (Figure 9B). The camera port in RA-MIDCAB is usually extended into a mini-thoracotomy incision without rib-spreading (Figure 9C), with the sequence of revascularization usually following routine off-pump CABG principles of first targeting the LAD (73,74). For TECAB, an additional 12- or 15-mm sealed port (Ethicon Surgical, Somerville, NJ, USA) is established in the 2^nd intercostal space in the midclavicular line, which functions as an access port for coronary shunt insertion, sutures or the automated C-Port Flex A^TM device. The pericardial fat pad is dissected free and reflected laterally, after which the pericardium is incised anterior to the phrenic nerve towards the cardiac apex for LAD exposure and posterior to the phrenic nerve for circumflex-marginal target vessel access. Before dividing the ITA and before systemic heparinization, the target vessels are stabilized by the Endo-Wrist^TM stabilizer, carefully exposed and isolated proximally with a Saddleloop^TM snare (Quest Medical, Allen, TX, USA). Expert TECAB centres advocate a brief period of monitored ischemic preconditioning (38-44), which allows time to introduce sutures and shunts into the thoracic cavity and to introduce Black Diamond^TM forceps into both robotic arms. After the ITA conduits are appropriately tailored to the coronary anatomy, a coronary arteriotomy is performed with an endo-knife (Snap-Fit^TM; Intuitive Surgical, Sunnyvale, CA, USA), extended as needed, an appropriate sized shunt inserted and the anastomosis constructed by either a continuous running suture or by using an automated C-Port Flex A^TM anastomosis device (39,65-66). Ventricle perforation can be avoided by refraining from placing proximal coronary snare sutures through friable myocardium, using soft snares with gentle application and by carefully exposing intramuscular target vessels. Care should be taken to avoid contact or compression of the cardiac structures during robotic instrument manipulation within the right pleural space. Myocardial ischemia in off-pump MI-CABG can be prevented by efficient team communication of electrocardiogram (ECG) changes, ensuring adequate myocardial perfusion pressures, efficient shunt insertion and avoiding suction or compressive device occlusion of distal target vessel outflow. The team at the Catholic University of Leuven emphasised that the hemodynamic instability that potentially occur with cardiac manipulation within the thoracic cavity and the limited access to the aorta for proximal anastomosis, can be minimized by using bilateral ITA conduits in conjunction with other arterial conduits in Y-graft configurations (45).

Figure 9 Anastomosis construction is performed using the same incision in (A) direct vision, (B) a separate antero-lateral mini-thoracotomy in videoscopic assisted and by extension of the robotic camera port into an antero-lateral mini-thoracotomy without rib-spreading in (C) robotic assisted minimally invasive coronary artery surgery. All images used were either original or obtained from open access sources.

Procedure conclusion and post-operative care

The pericardium is usually loosely approximated in all MI-CABG approaches after ensuring adequate haemostasis, graft orientation and function. Subsequent wound and incision closures follow routine principles after appropriate sized drains are inserted. Patients are usually extubated 2–6 hours post-operatively, while tailored analgesia, anti-platelet therapy and other medication are administered as needed. Reports that describe the benefits associated with ultra-fast track/in-theatre extubation are progressively emerging with the intention of reducing hospitalization costs and to enhance postoperative recovery (82). Early ambulation and a structured individualised treatment pathway should be supervised by a multi-disciplinary rehabilitation team until home discharge is achieved (Figure 10).

Figure 10 Typical post-operative appearance of a minimally invasive surgical coronary revascularization patient.

Peripheral CPB and cardioplegic arrest

The anticipation of extensive cardiac manipulation, possible hemodynamic instability and buried target vessels are potential indications for planned peripheral CPB, with or without the use of cardioplegic arrest (35,45,50,62) and is usually performed through a 4-cm right groin incision that provide access to the common femoral vasculature. Total percutaneous cannulation using vascular closure devices can be utilised, but is not advocated if inexperienced or during the initial learning curve (50,81). Peripheral saturation monitoring of the cannulated limb is advised to detect hypoperfusion and the routine use of an additional distal perfusion cannula may be considered (62). External aortic clamping under direct or endoscopic assisted vision (Video 1), antegrade needle cardioplegia delivery and aortic root venting are frequently favoured within the context of cost constraints and availability (63,64). External clamping is preceded by the careful development of the aortic transverse sinus and the introduction of the device through a small separate incision in the 2^nd intercostal space. SC is strongly advocated if any difficulties are anticipated or occur (50).

Hybrid coronary artery revascularization

All MI-CABG approaches provide an excellent platform for hybrid revascularization, where the well-established survival benefits of ITA to LAD (83) are combined with contemporary PCI technology that outperform venous conduits for multi-vessel revascularization of non-LAD lesions (18). The benefits of complete revascularization are well reported and randomized control trials that compare conventional CABG with the planned combination of MI-CABG and PCI in different coronary targets within a predefined time-period, suggest similar procedural major adverse cardiac and cerebrovascular events (84-88). PCI is usually performed within 3 to 5 days following MI-CABG (50). Conduit patency and quality can be assessed during the PCI procedure and may potentially offer the additional reported benefits of decreased blood transfusion requirements, shorter hospitalization and rapid regain of preoperative functional status compared to conventional CABG (84-88).

Quality control, clinical governance and need for accreditation

Une (52) reported the safe initiation of MI-CABG without mortality or morbidity by advocating CPB assistance as a risk reduction strategy for SC. The off-pump CABG team at the Catholic University of Leuven (Belgium), reported that the early learning curves do not impact procedural safety and that the need for SC and repeat revascularization decreased significantly after the first 50 procedures (45). The surgical challenges in multi-vessel MI-CABG (89) and risk aversion strategies that aim to improve quality control and clinical governance (50) are well reported. Industry accreditation pathways objectively ensure that appropriate levels of theoretical knowledge and technical skills are mastered, maintained, and further developed.

Conclusions

The ongoing development of MI-CABG techniques and technology create an exciting platform where the traditional benefits of CABG by sternotomy access can be offered to patients with single- or multi-vessel coronary artery disease by less invasive approaches. The application of hybrid coronary revascularization is rapidly expanding and MI-CABG provides the opportunity for improved collaboration between cardiovascular specialities and referral bases. Appropriate infrastructure planning, team training, skills development, low-risk patient selection and collaboration with expert centres form the basis for the successful initiation of a safe and sustainable MI-CABG program. Patients are the greatest advocates of a successful MI-CABG program and every effort to reduce adverse outcome risk within a team context should be the priority.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “International Perspectives on Minimally Invasive Coronary Artery Revascularization.” The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.org/article/view/10.21037/jovs-22-43/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.org/article/view/10.21037/jovs-22-43/coif). The series “International Perspectives on Minimally Invasive Coronary Artery Revascularization” was commissioned by the editorial office without any funding or sponsorship. JvdM served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Visualized Surgery from February 2019 to January 2025. FC served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Visualized Surgery from February 2019 to January 2025. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was obtained from the patients for publication of this manuscript and any accompanying images and video.

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