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Ashenhurst et al. Vessel Plus 2024;8:3 https://dx.doi.org/10.20517/2574-1209.2023.90 Page 3 of 15

related to sternotomy, such as those with chronic tracheostoma or diabetes [5,19] , MICS CABG could be an
attractive alternative. Lastly, MICS CABG is also indicated for patients who prefer to undergo less invasive
procedures and lead an active lifestyle [17,20] .

Despite the advantages that come with the less invasive approach, certain patient presentations are
contraindicated for the procedure, including emergency cases, hemodynamic instability, severe chest wall
deformities (i.e., pectus excavatum), or severe pulmonary disease [5,17,20] . Relative contraindications include
left subclavian stenosis, hemodialysis arteriovenous fistula on the left side, morbid obesity, and moderate
[17]
valve disease or ventricular dysfunction .
LESS INVASIVE CARDIAC SURGERY APPROACHES
Comparison
With the rapid advancement of technology, several minimal techniques have been established and continue
to evolve. Table 1 categorizes each surgical procedure based on the incision employed and the respective use
of CBP.

The negative inflammatory risks associated with CPB [8-10] can be avoided by offering off-pump CABG
(OPCAB), which has become increasingly popular. In OPCAB, the bypass is performed through a median
sternotomy on a beating heart, without the use of a cardiopulmonary bypass machine. All regions of the
heart can be accessed for revascularization, though specialized equipment must be employed to stabilize the
coronary artery during grafting.

In the 1990s, an even less invasive single-vessel bypass surgery was performed without the use of bypass or
sternotomy . This technique, known as minimally invasive direct coronary artery bypass (MIDCAB),
[21]
involves grafting the left internal thoracic artery (LIMA) to the left anterior descending coronary artery
(LAD). Based on the anatomy of the incision, it is restricted to grafting only the LITA-LAD, which makes it
technically difficult to target severe or diffuse CAD. At MIDCAB’s inception, muti-vessel bypass grafting
was not considered feasible through a nonsternotomy incision.

However, in 2009, McGinn and Ruel demonstrated the systematic safety and feasibility of the evolution
towards multivessel MIDCAB, now known as minimally invasive coronary artery bypass grafting . MICS
[17]
CABG allows the surgeon to perform complete revascularization through a sternum-sparing small left
thoracotomy incision, often without the use of CPB . The incision allows access to all coronary territories
[17]
and a graft configuration comparable to that achieved with a sternotomy. The use of robotic technology has
further advanced the evolution of MICS CABG and permitted more complex grafts to be performed either
robotically assisted or totally robotically . Often, MICS CABG is coupled with percutaneous coronary
[22]
interventions in the context of Hybrid Coronary Revascularization (HCR) .
[23]
Surgical incisions
Median sternotomy is frequently used in cardiothoracic procedures requiring access to contents of the
mediastinum and is the most used incision for CABG. The opening and closing of the incision can be
associated with various post-op complications, but it can be performed safely with proper execution and
consideration [Figure 1].

On the other hand, as the name suggests, MIDCAB and MICS CABG utilize a significantly less invasive
incision, a small left thoracotomy, which is associated with a lower risk of post-op complications [17,20] .
Perioperative pain control can be achieved through paravertebral thoracic local anesthetic injection at the