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Page 2 of 15 Pusca et al. Mini-invasive Surg 2021;5:51 https://dx.doi.org/10.20517/2574-1225.2021.45

lesions in non-LAD territories have excellent short term patency rates (6.6% target vessel failure at 8
[6,7]
months, 8.9% target vessel failure at 3 years) comparable or superior to vein grafts to the same territories
[8]
(25% vein graft failure at 12-18 months) without the morbidity of CABG.
The hybrid strategy has a steep learning curve, particularly on the cardiac surgery side, because the LIMA
LAD anastomosis is done without a sternotomy in an off-pump or beating heart fashion. The strategy also
requires seamless teamwork between cardiac surgery and interventional cardiology.

The American College of Cardiology, American Heart Association, American College of Physicians,
American Association for Thoracic Surgery, The Preventive Cardiovascular Nurses Association, The Society
for Cardiovascular Angiography, and Interventions and The Society of Thoracic Surgeons have issued joint
guidelines for HCR, defined as the planned combination of LIMA-to-LAD artery grafting and PCI of one or
[9]
more non-LAD coronary arteries .
Class IIa indications include limitations of traditional CABG (heavily calcified ascending aorta, poor non-
LAD target vessels but amenable to PCI, lack of suitable graft conduits) and unfavorable LAD anatomy for
PCI (chronic total occlusion or excessive LAD tortuosity).

Class IIb indications include attempts to improve the overall risk-benefit ratio of both PCI and CABG in
patients who have multivessel coronary artery disease, would benefit from a LIMA to LAD bypass but have
other comorbidities that put them at risk of complications after surgery (recent MI, fraility) or need a rapid
return to baseline activities.

This article aims to distill the lessons that we have learned at Emory University over the past decade of
application of this strategy and provide guidance on the steps required to introduce it into the
armamentarium of an institution.

CABG WITHOUT STERNOTOMY (MINIMALLY INVASIVE CORONARY SURGERY)
[10]
Efforts to avoid partially or completely the sternotomy to perform CABG started in 1995 with Dr. Benetti .
At Emory, we moved in the early 2000s to harvest the LIMA using video-assisted thoracic surgery
techniques (VATS), a robotic arm, Aesop (Intuitive Surgical, Mountainview, CA) to hold the camera, and a
1.5-2-inch incision, if necessary with resection of costal cartilage, to perform the LIMA to LAD anastomosis
off-pump, using a port-based cardiac positioner (Medtronic, Minneapolis, MN. Guidant, Santa Clara, CA,
Estech, Danville, CA). The technique was called EndoACAB (endoscopic atraumatic coronary artery
bypass). A significant experience of 607 patients was accumulated with excellent results: 30-day mortality of
1%, a mean ICU length of stay of 11.2 ± 9.9 h, a hospital length of stay of mean 2.4 ± 1.3 days, a conversion
to sternotomy or standard thoracotomy of 3.6% (0.7% emergent) and 5-year survival of 92.9% ± 2.4% .
[11]
Unfortunately, the VATS technique to harvest the mammary was difficult to learn, mainly because the
LIMA was harvested with long-shafted instruments endoscopically. Such instruments amplify hand tremors
and have no articulation of the distal ends of the instruments to allow complex intrathoracic manipulations.
In addition, the Aesop robotic arm, essential for holding the camera, was unfortunately discontinued from
production. Furthermore, the advent of the robotic Da Vinci Surgical System (Intuitive Surgical Inc.,
Sunnyvale, CA) made this procedure somewhat obsolete.