Left Mammary Artery Harvesting Through a Left Minithoracotomy With Thoracoscopic Assistance

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This video shows the technique for harvesting the left internal mammary artery (LIMA) through a left minithoracotomy using thoracoscopic assistance. The authors recommend using a 30-degree or zero-degree scope and a retractor kit. 

The procedure began by dissecting the surrounding tissue laterally from the LIMA at the level of the incision and proceeding cranially. The internal thoracic fascia was then opened. Care was taken to ensure that the dissection remained sufficiently lateral to avoid damaging the LIMA or mammary veins. 

Once the LIMA was partially visualized, the side branches were carefully divided and isolated using precise electrocautery and by placing clips. While gradually moving cranially, the LIMA was gently pulled downward to stretch the soft tissues for better exposure. The authors advise using a semiskeletonized or in-flap technique, coagulating a few millimeters away from the LIMA to prevent trauma or vasoconstriction. Care was taken to grasp only the outer layer to avoid excessive trauma to the graft. The artery was harvested in both directions up to the level of the subclavian vein. The circular mobilization was then completed by dissecting the tissue medially from the artery. 

The harvesting concluded by moving toward the main incision in the fifth intercostal space, using the same technique. Once the LIMA was completely mobilized, a distal clip was applied and then cut with scissors or a LigaSure device. After harvesting was complete, papaverine was injected underneath the outer layer of the artery in addition to the conventional spray. This helps prevent vasoconstriction and prepares the LIMA for bypass grafting.  A LigaSure may also be used to improve the maneuverability of the graft. 

References

1. Kusu-Orkar TE, Kermali M, Masharani K, Noshirwani A, MacCarthy-Ofosu B, Oguamanam N, Bin Saeid J, Muir AD, Harky A. Skeletonized or Pedicled Harvesting of Left Internal Mammary Artery: A Systematic Review and Meta-analysis. Semin Thorac Cardiovasc Surg. 2021 Spring;33(1):10-18. doi: 10.1053/j.semtcvs.2020.09.010. Epub 2020 Sep 24. PMID: 32979482.
2. Rezk ME, Elgazzar MA, Abo Youssef SM, Emeraa AS, Elkafoury AE, Moussa HH. Open Versus Closed Pleura Internal Mammary Artery Harvesting and Early Pulmonary Function After Coronary Artery Bypass Grafting. Heart Lung Circ. 2020 Sep;29(9):1412-1417. doi: 10.1016/j.hlc.2019.09.014. Epub 2019 Nov 15. PMID: 31786114.
3. Gowda G S L, Kumar J H V, G S V, Mathew AK, Nanjappa MC. Effect of Papaverine on Left Internal Mammary Artery Flow: Topical Spraying versus Perivascular Injection Method. Braz J Cardiovasc Surg. 2020 Apr 1;35(2):181-184. doi: 10.21470/1678-9741-2019-0126. PMID: 32369298; PMCID: PMC7199983.

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