Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: Early outcomes and angiographic patency



      Multivessel minimally invasive coronary artery bypass grafting, performed chiefly with left internal thoracic artery and saphenous vein grafts through a left anterolateral thoracotomy, has recently emerged as an alternative to conventional coronary artery bypass grafting. The present study involves our initial experience with respect to early postoperative and angiographic outcomes after total arterial multivessel off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries.


      A total of 88 consecutive patients undergoing total arterial off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries without ascending aortic manipulation were included in this study. Bilateral internal thoracic arteries were harvested under direct vision through a left anterolateral thoracotomy and used as Y or in situ grafts. Multivessel grafting was performed off pump. Postoperative graft assessment was performed in 51 patients.


      The mean age of patients was 67.1 ± 7.2 years, and 79 patients (89.8%) were male. The mean body mass index and ejection fraction were 26.7 ± 2.7 kg/m2 and 57.6% ± 6.6%, respectively, and 40 patients (45.5%) had left main disease. No intraoperative conversions to cardiopulmonary bypass or sternotomy occurred. A total of 209 distal anastomoses (mean 2.4 ± 0.5) were performed, with 57 patients undergoing double, 29 patients undergoing triple, and 2 patients undergoing quadruple coronary artery bypass grafting. There was no in-hospital mortality, and 5 patients underwent reexploration for bleeding. No patient had stroke or chest wound infections. Predischarge coronary angiography revealed an overall graft patency rate of 96.8%.


      Off-pump minimally invasive coronary artery bypass grafting using total arterial revascularization with bilateral internal thoracic arteries is a feasible and safe operation that is associated with excellent short-term outcomes and early graft patency. Future studies should focus on improving the generalizability and reproducibility of this technique.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      BMI (body mass index), CA (coronary angiography), CABG (coronary artery bypass grafting), CI (confidence interval), CK (creatinine kinase), COPD (chronic obstructive pulmonary disease), CT (computed tomography), CTR (cardiothoracic ratio), IQR (interquartile range), ITA (internal thoracic artery), LAD (left anterior descending), LVEF (left ventricular ejection fraction), MICS (minimally invasive cardiac surgery), MIDCAB (minimally invasive direct coronary artery bypass), PCI (percutaneous coronary intervention)
      To read this article in full you will need to make a payment


        • Davierwala P.M.
        • Seeburger J.
        • Pfannmueller B.
        • Garbade J.
        • Misfeld M.
        • Borger M.A.
        • et al.
        Minimally invasive mitral valve surgery: “The Leipzig experience”.
        Ann Cardiothorac Surg. 2013; 2: 744-750
        • Diegeler A.
        • Spyrantis N.
        • Matin M.
        • Falk V.
        • Hambrecht R.
        • Autschbach R.
        • et al.
        The revival of surgical treatment for isolated proximal high grade LAD lesions by minimally invasive coronary artery bypass grafting.
        Eur J Cardiothorac Surg. 2000; 17: 501-504
        • Chang C.
        • Raza S.
        • Altarabsheh S.E.
        • Delozier S.
        • Sharma U.M.
        • Zia A.
        • et al.
        Minimally invasive approaches to surgical aortic valve replacement: a meta-analysis.
        Ann Thorac Surg. 2018; 106: 1881-1889
        • McGinn Jr., J.T.
        • Usman S.
        • Lapierre H.
        • Pothula V.R.
        • Mesana T.G.
        • Ruel M.
        Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients.
        Circulation. 2009; 120: S78-S84
        • Kikuchi K.
        • Chen X.
        • Mori M.
        • Kurata A.
        • Tao L.
        Perioperative outcomes of off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries under direct vision.
        Interact Cardiovasc Thorac Surg. 2017; 24: 696-701
        • Nambiar P.
        • Kumar S.
        • Mittal C.M.
        • Saksena K.
        Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: will this be the future?.
        J Thorac Cardiovasc Surg. 2018; 155: 190-197
        • Harskamp R.E.
        • Lopes R.D.
        • Baisden C.E.
        • de Winter R.J.
        • Alexander J.H.
        Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology, management, and future directions.
        Ann Surg. 2013; 257: 824-833
        • Roach G.W.
        • Kanchuger M.
        • Mangano C.M.
        • Newman M.
        • Nussmeier N.
        • Wolman R.
        • et al.
        Adverse cerebral outcome after coronary bypass surgery.
        N Engl J Med. 1996; 335: 1857-1863
        • Gaudino M.
        • Benedetto U.
        • Fremes S.
        • Biondi-Zoccai G.
        • Sedrakyan A.
        • Puskas J.D.
        • et al.
        • RADIAL Investigators
        Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery.
        N Engl J Med. 2018; 378: 2069-2077
        • Lytle B.W.
        • Blackstone E.H.
        • Sabik J.F.
        • Houghtaling P.
        • Loop F.D.
        • Cosgrove D.M.
        The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.
        Ann Thorac Surg. 2004; 78: 2005-2012
        • Yi G.
        • Shine B.
        • Rehman S.M.
        • Altman D.G.
        • Taggart D.P.
        Effect of bilateral internal mammary artery grafts on long-term survival a meta-analysis approach.
        Circulation. 2014; 130: 39-545
        • Calafiore A.M.
        • Di Mauro M.
        • Teodori G.
        • Di Giammarco G.
        • Cirmeni S.
        • Contini M.
        • et al.
        Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization.
        Ann Thorac Surg. 2002; 73: 1387-1393
        • Taggart D.P.
        • Altman D.G.
        • Gray A.M.
        • Lees B.
        • Nugara F.
        • Yu L.M.
        • et al.
        • ART Investigators
        Randomized trial to compare bilateral vs. single internal mammary coronary artery bypass grafting: 1-year results of the Arterial Revascularisation Trial (ART).
        Eur Heart J. 2010; 31: 2470-2481
        • Davierwala P.M.
        • Leontyev S.
        • Garbade J.
        • Lehmann S.
        • Holzhey D.
        • Misfeld M.
        • et al.
        Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience.
        Ann Cardiothorac Surg. 2018; 7: 483-491
        • Holzhey D.M.
        • Cornely J.P.
        • Rastan A.J.
        • Davierwala P.
        • Mohr F.W.
        Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease.
        Heart Surg Forum. 2012; 15: E61-E68
        • Ender J.
        • Borger M.A.
        • Scholz M.
        • Funkat A.K.
        • Anwar N.
        • Sommer M.
        • et al.
        Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.
        Anesthesiology. 2008; 109: 61-66
        • Zakhary W.Z.A.
        • Turton E.W.
        • Flo Forner A.
        • von Aspern K.
        • Borger M.A.
        • Ender J.K.
        A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients.
        Anaesthesia. 2019; 74: 602-608
        • Lemma M.
        • Atanasiou T.
        • Contino M.
        Minimally invasive cardiac surgery-coronary artery bypass graft.
        Multimed Man Cardiothorac Surg. 2013; 2013
        • Rabindranauth P.
        • Burns J.G.
        • Vessey T.T.
        • Mathiason M.A.
        • Kallies K.J.
        • Paramesh V.
        Minimally invasive coronary artery bypass grafting is associated with improved clinical outcomes.
        Innovations (Phila). 2014; 9: 421-426
        • Omer S.
        • Cornwell L.D.
        • Rosengart T.K.
        • Kelly R.F.
        • Ward H.B.
        • Holman W.L.
        • et al.
        Completeness of coronary revascularization and survival: impact of age and off-pump surgery.
        J Thorac Cardiovasc Surg. 2014; 148: 1307-1315
        • Benedetto U.
        • Caputo M.
        • Patel N.N.
        • Fiorentino F.
        • Bryan A.
        • Angelini G.D.
        Long-term survival after off-pump versus on-pump coronary artery bypass graft surgery. Does completeness of revascularization play a role?.
        Int J Cardiol. 2017; 246: 32-36
        • Mack M.J.
        • Head S.J.
        • Holmes Jr., D.R.
        • Ståhle E.
        • Feldman T.E.
        • Colombo A.
        • et al.
        Analysis of stroke occurring in the SYNTAX trial comparing coronary artery bypass surgery and percutaneous coronary intervention in the treatment of complex coronary artery disease.
        JACC Cardiovasc Interv. 2013; 6: 344-354
        • Houlind K.
        • Kjeldsen B.J.
        • Madsen S.N.
        • Rasmussen B.S.
        • Holme S.J.
        • Nielsen P.H.
        • et al.
        • DOORS Study Group
        On-pump versus off-pump coronary artery bypass surgery in elderly patients: results from the Danish on-pump versus off-pump randomization study.
        Circulation. 2012; 125: 2431-2439
        • Furukawa N.
        • Kuss O.
        • Preindl K.
        • Renner A.
        • Aboud A.
        • Hakim-Meibodi K.
        • et al.
        Anaortic off-pump versus clampless off-pump using the PAS-Port device versus conventional coronary artery bypass grafting: mid-term results from a matched propensity score analysis of 5422 unselected patients.
        Eur J Cardiothorac Surg. 2017; 52: 760-767
        • Kosmidou I.
        • Chen S.
        • Kappetein A.P.
        • Serruys P.W.
        • Gersh B.J.
        • Puskas J.D.
        • et al.
        New-onset atrial fibrillation after PCI or CABG for left main disease: the EXCEL Trial.
        J Am Coll Cardiol. 2018; 71: 739-748
        • Kon Z.N.
        • Brown E.N.
        • Grant M.C.
        • Ozeki T.
        • Burris N.S.
        • Collins M.J.
        • et al.
        Warm ischemia provokes inflammation and regional hypercoagulability within the heart during off-pump coronary artery bypass: a possible target for serine protease inhibition.
        Eur J Cardiothorac Surg. 2008; 33: 215-221
        • Benedetto U.
        • Altman D.G.
        • Gerry S.
        • Gray A.
        • Lees B.
        • Pawlaczyk R.
        • et al.
        Pedicled and skeletonized single and bilateral internal thoracic artery grafts and the incidence of sternal wound complications: Insights from the Arterial Revascularization Trial.
        J Thorac Cardiovasc Surg. 2016; 152: 270-276
        • Une D.
        • Lapierre H.
        • Sohmer B.
        • Rai V.
        • Ruel M.
        Can minimally invasive coronary artery bypass grafting be initiated and practiced safely?: a learning curve analysis.
        Innovations. 2013; 8: 403-409
        • Ruel M.
        • Shariff M.A.
        • Lapierre H.
        • Goyal N.
        • Dennie C.
        • Sadel S.M.
        • et al.
        Results of the minimally invasive coronary artery bypass grafting angiographic patency study.
        J Thorac Cardiovasc Surg. 2014; 147: 203-208