Mini OPCAB Mammary to Left Anterior Descending Artery

Introduction: Here we will describe the actual surgical technique to perform the left mammary artery bypass to the left anterior descending artery, and the results of this operation in the Benetti Foundation in the last 20 years. Materials and Methods: The inclusion criteria for this operation were patients with a demonstrated predominant ischemia by functional test. In the patients with double, triple vessels disease or left main, the age was more than 65 years or and Euro score Risk of surgery of more than 4. The exclusion criteria were patients with more areas of ischemia and lesions that involved a considerable territory apart from the Lad and good candidates for surgery are younger than 65 years or the Euro score Risk of surgery were less than 4. Seventy patients were operated in the Foundation through LIMA to LAD Anastomosis with the MINI OPCABG technique. The average Preoperative Risk Euroscore was 3,5. Surgical Technique after open the lower part of the sternum, the left mammary artery is dissected around 8 cm. The pericardium is open and the mammary is connected to the left anterior descending. Results: Operative mortality in this series was 0%. One patient was converted to sternotomy Off Pump (1, 4%). None of the grafts were revised after the measure with the Medistim System. 55 (79%) were extubated in the operating room. The average Hospitalization stay were 60 hours (D +_17 ci 95%), 16 patients with Lima to LAD were restudied in the initially experience with 100% patency, at 144 months, 82% of the patients were alive and 68% asymptomatic. Conclusion: More clinical experience is important to find the definitive indications of this technique; and better technologies are required to be able to standardize this operation in definitive form.


Introduction
Trying to decrease the risks of the CABG and costs, in 1978 we popularized the Off Pump Coronary Artery Bypass Graft (OPCABG) and expanded the technique, addressing lesions of the circumflex system (CX) and applying it to diverse clinical scenarios [1] [2].Several surgical approaches were tested, such as full sternotomy, no spreading sternotomy including left, anterolateral, posterolateral and right anterolateral thoracotomies, as well as partial sternotomy [3].
The video-assisted techniques in the nineties allowed, for the first time, to dissect the left internal thoracic artery (LITA) without opening the pleura cavity.
The LITA was anastomosed to the left anterior descending (LAD) through a small left anterior thoracotomy [4] [5] [6].In 1997, we performed for the first time an ambulatory coronary bypass through a xiphoid lower sternotomy incision (MINI OPCAB) using 3D technology to assist in the operation [7] [8].

Surgical Technique
The patient is prepared as for standard Coronary bypass operation through sternotomy (Figure 1).The sternum is open up to the 3 or 4 intercostal space depending the anatomy (Figure 2).The mammary retractor is put place (Figure 3).The left mammary was dissected in general around 8 cm and isolated without    the veins (Figure 4).Importantly the angle of the superior part, were the mammary is attached to the sternum, needs to be below 20% to avoid any potential kinking.After the pericardium was cleaned to identify the area of the pulmonary artery.The pericardium is open to the apex and towards the right around 5 to 6 cm initially in that moment in most of the case the area of the LAD is seen and the potential area of the anastomosis is defined (Figure 5).The patient is heparinized and the LAD occluded with 5-0 Prolene.The mechanical stabilizer is posisionate and the anastomosis is performed (Figure 6).When the bypass is finished, and before tied the suture the stitches of 5-0 polypropylene around the artery is released and the clamp of the mammary also and the anastomosis is tied.The mechanical stabilizer was take out, the stitches of the pericardium are released and the flow of the graft was measured being sure there is not any kinking, if the flow and the PR are ok the mammary is fixed with 2 stiches of 7-0 polypropylene in both sides around 1 cm from the   anastomosis.The heparin is reverted with protamine, a drainage is put in placewith the caution of avoiding any chance of touching the mammary or the anastomosis.The sternum is closed with 1 or 2 wires.

Results
Operative mortality in this serie was 0%; one patient was converted to sternotomy Off Pump (1, 4%) None of the grafts were revised after the measure with the Medistin System 55 (79%) were extubated in the operating room The average Hospitalization stay were 60 hours (D +_17 ci 95%), 16 patients with Lima to LAD were restudied in the initially experience with 100% patency; at 144 months 82% of the patients were alive and 68% asymptomatic [9].

Discussion
Old patients with multivessel coronary artery disease (CAD) are a challenging group to treat; these cases elicit discussion within heart teams regarding the actual benefit of undertaking major surgery on these patients and often lead to abandon the surgical option.Since these patients usually present with age-related comorbidities, preoperative risk stratification is mandatory and less invasive treatment options are favorable.Although conventional surgical revascularization can be carried out in old patients with acceptable short-and long-term results, perioperative mortality is markedly elevated [10].For high-risk patients with multivessel CAD, not eligible to on-pump complete revascularization surgery or percutaneous procedures, incomplete revascularization with OPCAB LIMA-on-LAD offers benefits in survival when compared to OMT (Optimal medical treatment) alone [11].
Coronary surgery without extracorporeal circulation is routinely performed by different incisions; the operation of MIDCAB creates two obstacles to be able to externalize the patient in an immediate way; the pain and the opening of the

Figure 1 .
Figure 1.The patient is prepared for a normal sternotomybetween the fingers you can see the size of the incision.

Figure 2 .
Figure 2. The sternum is open at the level of 3 or 4 intercostal space.

Figure 4 .
Figure 4.The mammary was dissected around 8 cm skeletonized and the anglein the upper part is below 20 degrees to avoid kinking.

Figure 5 .
Figure 5. Visualization of the LAD and mammary showing the distances.

Figure 6 .
Figure 6.This picture shows the mammary to LAD anastomosis finished, the retractor and mechanical stabilizer in position.