A New Technology Platform And Techniques For Sternal Sparing Coronary Revascularization Surgery
Eric Ndikumana1, Kyle C. Purrman2, Hossein Amirjamshidi1, Peter A. Knight1, Jude S. Sauer2.
1University of Rochester Medical Center, Rochester, NY, USA, 2LSI SOLUTIONS, Victor, NY, USA.
OBJECTIVE: Less invasive coronary artery bypass graft (CABG) surgery is underused despite more than 25 years of interest from surgeons and growing patient demands for less pain and rapid, full recovery. To advance surgical coronary revascularization, a dedicated innovation effort was undertaken with two critical technical objectives: uncompromised subxiphoid bilateral internal thoracic artery (BITA) harvest and the ergonomic creation of durable anastomoses through small thoracotomy access. Patients deserve the proven benefits of multi-arterial coronary bypass grafting through soft tissue access.
METHODS: This evolving novel technology platform currently comprises 4 main categories of devices: modular table-mounted retractor system with task-specific features (e.g., retrosternal retractors customized for LITA and RITA exposure, readily adjustable cannulas, additional tissue positioning accessories, etc.) optimized for videoscopic assisted subxiphoid BITA harvest; malleable shafted axial guide device for gentle distraction of ITAs for clipping and energy dissection; adjustable tissue pedestal atraumatically orients the ITA cobra head adjacent to coronary target site for accurate anastomotic suturing through remote access; automated manually powered 3mm shaft device crimps a tiny titanium fastener to secure and trim 6-0, 7-0 or 8-0 polypropylene suture. After extensive testing in ex vivo porcine heart, porcine carcass, and cadaver models, initial evaluation of technology platform components in patients undergoing CABG surgery was safe and encouraging.
RESULTS: Successful BITA harvest: 53/53 porcine carcasses and 11/11 cadavers with 127 total ITAs harvested to date. ITA to coronary artery anastomoses in 27 explanted porcine hearts and 23 porcine carcasses provided 50/50 successful anastomoses during development. Recently, partial RITA harvests were achieved via subxiphoid access in two MIDCAB patients. The axial guide demonstrated usefulness in BITA in 4 full-sternotomy CABG patients. 30/30 tiny titanium fasteners were successfully deployed by 7 surgeons in 11 CABG patients since its June 2021 clearance for use in the United States.
CONCLUSION: The initial evaluation of this new evolving technology platform and its associated techniques for multi-arterial coronary revascularization through small soft tissue access offers early encouragement. Widespread adoption of this opportunity may provide the proven benefits of CABG surgery to people with coronary artery disease without many of its current drawbacks. 
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