Evaluation of Robotic Coronary Surgery With Intraoperative Graft Angiography and Postoperative Multislice Computed Tomography Thomas Schachner, MD, Gudrun.

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Evaluation of Robotic Coronary Surgery With Intraoperative Graft Angiography and Postoperative Multislice Computed Tomography Thomas Schachner, MD, Gudrun M. Feuchtner, MD, Johannes Bonatti, FETCS, MD, Nikolaos Bonaros, MD, Armin Oehlinger, MD, Eva Gassner, MD, Otmar Pachinger, MD, FESC, Guy Friedrich, MD, FESC The Annals of Thoracic Surgery Volume 83, Issue 4, Pages 1361-1367 (April 2007) DOI: 10.1016/j.athoracsur.2006.10.054 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Setting of intraoperative graft angiography in a patient who underwent totally endoscopic coronary artery bypass graft surgery. The left internal mammary artery catheter is advanced through the left femoral artery, which was already exposed for extracorporeal circulation. A mobile C-arm is used for fluoroscopy. The patient is still draped sterilely and fully anesthetized, enabling immediate bypass revisions if necessary. The Annals of Thoracic Surgery 2007 83, 1361-1367DOI: (10.1016/j.athoracsur.2006.10.054) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Hybrid revascularization. (a) The 64-slice computed tomography images of a 52-year-old man with a poststenotic coronary aneurysm (C) of the left anterior descending (LAD) artery, which precluded LAD stenting. Therefore, the patient was treated with totally endoscopic single left internal mammary artery (LIMA) grafting to the LAD and the simultaneous implantation of a cypher stent (Cordis; Johnson & Johnson, New Brunswick, NJ [black arrow]) into the circumflex artery (CX) intraoperatively during one session (hybrid revascularization). The coronary aneurysm (C) releases both diagonal branches (DG). The image was reconstructed in three dimensions by applying a volume-rendering technique. Note that four vessels are arising from the aortic arch (1 = innominate artery; 2 = left common carotid artery; 3 = left vertebral artery; and 4 = left subclavian artery), which is useful information before performing arrested-heart totally endoscopic coronary artery bypass graft surgery. White spots at the aortic arch indicate calcifying plaque. (b) The corresponding catheterized angiography image shows the LIMA graft patent, with a good runoff distal into the LAD. The Annals of Thoracic Surgery 2007 83, 1361-1367DOI: (10.1016/j.athoracsur.2006.10.054) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Double-vessel totally endoscopic coronary artery bypass graft. Image from a 66-year-old man who underwent double-vessel endoscopic revascularization is shown. (a) The right internal mammary artery (RIMA) was sutured to the left anterior descending artery (LAD). (b) The left internal mammary artery (LIMA) was connected to the circumflex artery (CX). The black arrow indicates the anastomosis (A). Both grafts were patent on both 64-slice computed tomography and intraoperative angiography. Note that the distal target vessel was found to be well opacified on multislice computed tomography, suggesting a good distal runoff. The Annals of Thoracic Surgery 2007 83, 1361-1367DOI: (10.1016/j.athoracsur.2006.10.054) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Single-vessel totally endoscopic coronary artery bypass graft. (a) Image from a 59-year-old man in whom single left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting was performed. Graft patency was assessed with 16-slice computed tomography by applying a volume-rendering technique. (b) Computed tomography images using a maximum intensity projection technique, which is advantageous for the display of the graft lumen and for determining patency. (c) Invasive angiography confirmed LIMA graft patency. The Annals of Thoracic Surgery 2007 83, 1361-1367DOI: (10.1016/j.athoracsur.2006.10.054) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Single-vessel totally endoscopic coronary artery bypass graft. Image from a 61-year-old asymptomatic man presenting with an 80% stenosis (S) of the left anterior descending artery (LAD) distal to the anastomosis (A) after left internal mammary artery (LIMA) grafting. (A) Black arrows indicate the stenotic segment (S) after the anastomosis (A) on both (a, b) 16-multislice CT and (c) invasive angiography. (A) White arrows denote an aortocoronary venous graft to the obtuse marginal branch. (c) Note that the retrograde filling of the LAD was absent on invasive angiography. The Annals of Thoracic Surgery 2007 83, 1361-1367DOI: (10.1016/j.athoracsur.2006.10.054) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions