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Left Internal Mammary Artery Operative Topography For The Midcab And Tecab Procedures
Daniel J. Rams1, Jakub Batko1, Krzysztof Bartuś, Prof.2, Radosław Litwinowicz, MD, PhD2.
1Jagiellonian University Medical College, Kraków, Poland, 2Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, JP II Hospital, Kraków, Poland.

BACKGROUND: There are no studies on the operative topography of the left internal mammary artery (LIMA) during minimally invasive procedures such as minimally invasive coronary artery bypass grafting (MIDCAB) or total endoscopic coronary artery bypass grafting (TECAB). The aim of this study was to perform a detailed analysis of the LIMA surgical topography during minimally invasive harvesting and to present its most common anatomical variants. METHODS: 104 angio-CT studies were retrospectively reviewed. Raw data were processed using 3D reconstruction and visualisation software. Measurements were designed for the approach of the 4th costal cartilage, the anatomical midpoint of the sternal body (SBMP). Length, width, distance to the distal bifurcation, LIMA position of the bifurcation in the intercostal space, sternal distances, distance between both internal mammary arteries, and LIMA distances to individual segments of the left coronary artery and its descending branch were assessed. RESULTS: The average width of LIMA was 2.7mm, the length from the SBMP to the distal LIMA bifurcation was 6.2cm, the distance from the SBMP to LIMA 3.2±0.5cm, the distance from the xiphoid midpoint to LIMA 3.5±0.7cm, the distance from LIMA to the sternal line 1.7±0.3cm, the projection of the xiphoid end to the distal LIMA bifurcation 2.2±1.0cm, the distance between the distal LIMA bifurcation and its projection to the midsternal line was 3.3±0.8cm, the diagonal between the xiphoid end and the distal LIMA bifurcation was 4.1±0.9cm. The distances between LIMA and the left coronary artery were 5.5±1.1cm at the proximal level and 4.3cm at the distal level. The distances between LIMA and the proximal, middle and distal parts of the descending branch were 4.2±1.5cm, 7.0±1.4cm and 7.1±1.3cm, respectively. The most common position of distal LIMA bifurcation was at the level of the 6th intercostal space (66%). CONCLUSIONS: With increasing experience in minimally invasive surgery, a thorough understanding of LIMA topography is critical to perform elective surgery without compromise. LEGEND: Left: LIMA distal bifurcation occurence mapped on intercostal spaces. Right: LIMA and left coronary artery topography shown in 3D model representation. Visible structures: sternum, LIMA, aorta and left coronary artery with its branches.

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