To intervene or not to intervene: Lessons learned from completion angiography after robotic-assisted coronary bypass surgery

Abstract

Central MessageConservative management of initial graft failure after robotic-assisted CABG in select patients may lead to positive outcomes.See Commentaries on pages 194 and 196. Conservative management of initial graft failure after robotic-assisted CABG in select patients may lead to positive outcomes. See Commentaries on pages 194 and 196. Minimally invasive coronary artery bypass surgery (CABG) is being increasingly performed and robotic-assisted left internal mammary artery to left anterior descending (LIMA-LAD) grafting has been shown to have comparable clinical outcomes to traditional CABG1Halkos M.E. Liberman H.A. Devireddy C. Walker P. Finn A.V. Jaber W. et al.Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery.J Cardiovasc Surg. 2014; 147: 179-185Scopus (54) Google Scholar while avoiding the morbidity associated with sternotomy. Although completion angiography is not the standard of care for post-CABG patients, we have routinely performed an angiogram in patients after robotic-assisted CABG either in a hybrid room immediately after the procedure, or postoperatively in the catheterization lab. This practice was almost universal in the first several hundred cases and is still routinely done during hybrid revascularization cases. We present a case in which the initial completion angiogram revealed distal LAD occlusion consistent with graft failure; however, the 1-year angiogram showed a widely patent LIMA-LAD anastomosis. The patient was an active 80-year-old man with a history of coronary artery disease status post percutaneous coronary intervention (PCI) to the proximal LAD, hypertension, and atrial fibrillation who presented with exertional chest pain. Echocardiography demonstrated left ventricular ejection fraction 40%. Angiography revealed a chronic total occlusion of his LAD with distal filling via collaterals (Figure 1, Video 1), and we proceeded with robotic-assisted CABG. The da Vinci (Intuitive Surgical, Sunnyvale, Calif) robot was used to harvest the LIMA, open the pericardium, and identify the distal LAD target (Video 2). When this was completed, a 3- to 4-cm non–rib-spreading mini-thoracotomy was created for distal anastomosis. The distal LAD was identified and was extremely small, <1 mm, and was stabilized with the Nuvo off-pump stabilizer (Medtronic Corporation, Minneapolis, Minn). The LIMA-LAD anastomosis was then performed off-pump, manually, using an 8-0 polypropylene suture. A completion angiogram demonstrated poor flow distally, despite intracoronary nitroglycerin; however, there was some retrograde filling of the septal and diagonal vessels (Figure 2, Video 3). Given the small nature of the vessel, the team felt that further attempts at revascularization would be futile. The patient's postoperative course was unremarkable, and he was discharged home on postoperative day 3. He was seen 12 days postoperatively and was increasing his activity with no angina symptoms, and by 1 month he had resumed all of his previous activities with no angina. Twelve months after surgery a left heart catheterization was completed for clearance before spine surgery, revealing a patent LIMA-LAD graft (Figure 3, Video 4) with good antegrade and retrograde flow. We did not obtain consent specifically for writing this report because no identifiable data was used. In addition, our surgical consent that the patient signed included consent for the use of photographs or videos.Figure 2Completion angiogram, left anterior oblique 17 cranial 10 projection, after robotic-assisted left internal mammary artery to left anterior descending demonstrating poor flow distally, despite intracoronary nitroglycerin. Some retrograde filling of the septal and diagonal branches is seen.View Large Image Figure ViewerDownload (PPT)Figure 3Angiogram obtained 12 months postoperatively for cardiac clearance before spine surgery revealing a patent left internal mammary artery to left anterior descending graft