Additional right-sided upper “Half-Mini-Thoracotomy” for aortocoronary bypass grafting during minimally invasive multivessel revascularization

Evolving surgical strategies, such as OPCAB and MICS, are specifically developed to
improve short- and long-term outcomes and to reduce the level of invasiveness of CABG.
However, although prone to be beneficial for the patients in terms of reduced rates
of transfusion and wound-infection as well as enhanced recovery to full activity and
greater patient acceptance 3], overall adoption rates of MICS-CABG approaches remain low 1]. Usually performed through single-thoracotomy or port-access based they are either
restrained to specific indications or hybrid approaches because of restricted grafting
possibilities (MIDCAB), have to deal with increased susceptibility of arterial grafts
to competitive flow 4] (MVST), need specialized infrastructure and training (totally endoscopic coronary
artery bypass – TECAB) and are usually prone to conversion to full-sternotomy in case
of LITA insufficiency.

Although, minimally invasive multivessel revascularization with aortocoronary bypass
grafting performed through single-thoracotomy 5] is possible and has been shown to result in excellent clinical outcomes 6] as well as angiographic graft patency 7] adoption rates remain low. Here, the technical complexity – demanding intricate exposure
maneuvers to anastomose grafts onto the ascending aorta while being highly dependent
on favorable patient anatomy – is probably one of the major concerns in surgeons not
experienced with this approach, restraining the applicability of MICS-CABG surgery
to a small number of surgeons and patients.

As demonstrated in this report, an additional right-sided upper “half-mini-thoracotomy”
can be an easy to adopt alternative to current MICS-CABG approaches, allowing for
aortocoronary bypass grafting in standard OPCAB manner and liberal adoption of similar
revascularization principles as with conventional CABG. Although this means having
an additional “small scar” on the upper right thorax, patients can hereby potentially
be spared a full-sternotomy without need to compromise in the number of employed grafts.