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Anastomotic Techniques for Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass (TECAB)

Tuesday, March 13, 2018

Mitzman B, McCrorey M, Patel B, Balkhy HH. Anastomotic Techniques for Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass (TECAB). March 2018. doi:10.25373/ctsnet.5959594.

Robotic totally endoscopic coronary artery bypass (TECAB) surgery using the da Vinci surgical robot is an excellent way to provide high quality, minimally invasive coronary reperfusion to a patient who does not want, or cannot tolerate, a sternotomy. Many surgeons have mastered robotic internal mammary artery harvest, but performing the remainder of the operation proves difficult for most.

This video demonstrates the operation, which was performed for a 67-year-old man with severe left anterior descending and diagonal disease. Beginning after the left internal mammary artery (LIMA) takedown and identification of coronary targets, two separate techniques for coronary anastomosis on a beating heart are shown.

An end-to-side anastomosis is performed directly to the left anterior descending artery, using the Cardica C-Port™ Flex-A™ distal anastomotic stapler. This device uses a row of interrupted stainless steel staples to rapidly create a high-quality coronary anastomosis, even in low-quality calcified targets such as those seen in this patient.

A sequential side-to-side anastomosis is then created from the mid-LIMA to the diseased diagonal branch. This is performed in a hand-sewn fashion with a Gore-Tex™ suture, using a double shunt technique. One shunt is placed in the coronary to provide adequate coronary perfusion during the anastomosis creation, while keeping the field free from blood. The second shunt is placed in the LIMA, to prevent any back-walling while suturing down the graft.

Not only can the grafts be checked visually with the enhanced magnification of the robot, but they are all quantitatively tested using a time-transit flowmetry device. The device is able to check graft patency via multiple parameters, including pulsatility index, blood flow, and percent of diastolic coronary flow. Most patients recover from this operation very quickly with minimal postoperative pain. The target discharge date is postoperative day two.

Suggested Reading

  1. Balkhy HH, Wann LS, Krienbring D, Arnsdorf SE. Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: review of 120 Cases. Ann Thorac Surg. 2011;92(3):821-827.
  2. Srivastava S, Gadasalli S, Agusala M, et al. Beating heart totally endoscopic coronary artery bypass. Ann Thorac Surg. 2010;89(6):1873-1879.
  3. Argenziano M, Katz M, Bonatti J, et al. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting. Ann Thorac Surg. 2006;81(5):1666-1674.
  4. Bonatti J, Lee JD, Bonaros N, Schachner T, Lehr EJ. Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results. Innovations (Phila). 2012;7(1):3-8.


Dr Balkhy is a proctor for Intuitive Surgical and a consultant for Dextera Surgical.


Guillermo Stroger -- Mean time for a single vessel TECAB (lima/LAD) for our group is now averaging 2.5 hours. Quickest was 93 minutes. For a 2 or 3 vessel TECAB, add about 1.5 - 2 hours for RIMA takedown and additional anastomosis. Rafiq Khan -- The flex-a stapler was validated for open CABG and is perfectly safe. A multicenter european trial showed 95% vein graft patency at 6 months. It significantly speeds up the robotic operation . As shown in the video, it is still feasible to do hand-sewn when needed. Here are some references: Matschke, K.E., Gummert, J.F., Demertzis, S. et al. The Cardica C-Port System: clinical and angiographic evaluation of a new device for automated, compliant distal anastomoses in coronary artery bypass grafting surgery–a multicenter prospective clinical trial. J Thorac Cardiovasc Surg. 2005; 130: 1645–1652 Balkhy, H.H., Wann, L.S., and Arnsdorf, S.E. Early patency evaluation of new distal anastomotic device in internal mammary artery grafts using computed tomography angiography. Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery. 2010; 5: 109–113
Thank you Dr. Mitzman for presenting this excellen work. We have made similar experience for sequential LIMA grafting to the anterior wall in 2004 at Frankfurt University/Germany using the first version of the daVinci robotic system. (Totally endoscopic sequential arterial coronary artery bypass grafting on the beating heart. Koray Ak, MD,Gerhard Wimmer-Greinecker, MD, Omer Dzemali, MD, Anton Moritz, MD, Selami Dogan, MD) Canadian Journal of Cardiology 2007. However, we did hand sewn anastomoses to the LAD and D1 and were not satisfied with the previous results of the so called MVC (magnetic vascular coupler) that we used for automated vascular anastomosis. I still think that this type of Surgery remains experimental since the same operation can be done in 1 hour in conventional open off-pump technique. The long term quality of automated anastomoses will determine its use in endoscopic surgery.

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