New Surgical Platform: Subxiphoid Bilateral Internal Thoracic Artery Harvesting For All Arterial Coronary Revascularization
Hossein Amirjamshidi1, Jude S. Sauer2, Bryan Barrus1, Peter A. Knight1, Sunil Prasad1.
1Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA, 2LSI SOLUTIONS, Victor, NY, USA.
BACKGROUND: Bilateral internal thoracic artery (BITA) grafting remains significantly underutilized in coronary artery bypass graft (CABG) surgery. Sternal sparing coronary surgical revascularization is also infrequently employed. An ideal coronary vascularization operation would provide excellent quality all arterial anastomoses without transecting bones or cartilage or touching the aorta. This study reports on the initial progress towards developing a multi-faceted technology platform to enable fast, gentle and reliable BITA harvesting through a subxiphoid approach, customized ITA “cobra head” stabilizing devices to augment minimally invasive anastomotic suturing and a miniature titanium fastener for 6, 7 and 8-0 polypropylene suture. METHOD: Novel table-mounted substernal retractors were inserted through the subxiphoid space and behind the sternum providing ample working space to harvest each IMA under direct and videoscopic viewing (Figure 1). Two new devices for gentle, rapid remote dissection were utilized along with specialized device holders. Harvested ITA segments were subsequently used for evaluating the “cobra head” stabilized adjacent to the left anterior descending (LAD) artery to simplify ITA-LAD end-to-side anastomotic suturing of 8-0 polypropylene suture, which was secured via titanium fastener placement with simultaneous suture trimming. RESULTS: This subxiphoid approach was performed in 3 cadavers and 14 porcine carcasses (26 ITAs) with all ITAs successfully harvested in a skeletonized fashion. Porcine in situ graft ITA length averaged 12-14cm; the mean harvesting time was 19 minutes, range 13 to 25, in the last 10 harvests simulating use of an energy dissection device. 10 ITAs were anastomosed to ex-vivo porcine heart LADs aided by the “cobra head” stabilizing device. >1000 miniature titanium fasteners were placed successfully demonstrating ease-of-use and strength. CONCLUSIONS: The vast majority of patients with ischemic heart disease have not fully benefited from the potential advances in surgical coronary vascularization. Techniques and technology to facilitate cost effective, all arterial aortic and sternal sparing coronary vascularization is worthy of focused attention in this era exploring utilization of radial arteries, OPCAB and Hybrid / TCAB / MIDCAB / MICSCAB options. These early results encourage aggressively pursuing an optimized minimally invasive CABG option affordable for patients across the world. 
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