Multivessel Coronary Bypass Grafting With Minimal Access Using Cardiopulmonary Bypass (Port Access Approach)

p ort access coronary artery bypass grafting (PACABG) has evolved significantly since its introduction in 1996. New technological developments, procedural changes, and operator experience have led to improved understanding of the potential benefits anti pitfalls of the procedure. At our hospitals, Memorial Mission Hospital and New York University Hospital, more than 600 coronary revascularizations have been performed with the port access platform. Tiffs article reviews the teclmique, patient selection process, and results associated with the procedure. PRINCIPLES The technique of PACABG is based on the principles that have made standard on-pump CABG a successfnl operation for treating coronary artery disease. Cardioplegic-induced cardiac arrest with cardiopulmonary support allows for improved visibility, enhanced precision of anastomosis, and cardiac decompression with access to all regions of the heart for complete target revascularization. With port access, the cardiac operation is performed via a small anterior thoracotomy while the patient is maintained on a new system of cardiopulmonary bypass that uses peripheral cannulation to support the patient during peripherally manipulated cardiac arrest. Thus, the patient's recovery is not impaired by skeletal healing. The hypothesis is that the sternotomy itself slows the recovery process and adds morbidity to the operation that may be avoided with peripheral perfusion. This cannula system was refined through extensive laboratory studies confirnfing its efficacy and safety. Reliable myocardial protection and cardiopulmonary support have been documented with this technique, l When clinical trials were begun in 1996, it became evident that significant changes in the operating room were required to achieve excellent outcomes. First, the anesthesia, perfusion, nursing, and surgical staffs were required to learn new skill sets. Second, communication within and between these disciplines, along with critical analysis of each member's role, required review and expansion. This team approach has been shown to be one of the crucial retluirements to suecessfifl adoption of this new procedure. The importance of nonsurgeon ioput to the proeeditre cannot be overemphasized. Suecessfid apl)lieation of PACABG is not solely al)out a surgeon mastering a new operation, but rather about an operating team bringing together a critical mass of skills to perform this new procedure. 2 The initial CABG experience was focused on the area from the left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass. 3 Subsequently, with operator experience, muhivessel procedures became more common. With these initial nmhivessel procedures, graft inflow was based on the LIMA. The LIMA was anastomosed to the LAD, and radial arteries or saphenous veins were taken as side grafts to non-LAD targets. As surgeons continued to modify the operation, access to the aorta became routinely achievable. This enabled the more conventional operation of non-IMA conduits to be based off the aorta, This significantly decreased operative times and simplified and improved the applicability of the procedure. 4