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Totally Endoscopic Multivessel Coronary Revascularization In A High-risk Patient With Prior Chest Radiation And Bilateral Ita Grafting: A Case Report
Yazan N. AlJamal1, Husam Balkhy
2.
1Mayo Clinic, Rochester, MN, USA,
2University of Chicago, Chicago, IL, USA.
OBJECTIVE: To demonstrate the feasibility and safety of robotic multivessel Totally Endoscopic Coronary Artery Bypass (TECAB) using bilateral internal thoracic arteries (BITA) in an extremely high-risk patient with significant comorbidities—including prior chest radiation, chronic respiratory failure, and advanced peripheral vascular disease—who was deemed inoperable via sternotomy.
METHODS: A 69-year-old male presented with progressive dyspnea on exertion and severe three-vessel coronary artery disease. Comorbidities included prior chest radiation, chronic hypoxic respiratory failure on home oxygen, recurrent pleural effusions, CKD stage III, and left below-knee amputation. He was declined for sternotomy by multiple centers. He was offered robotic multivessel TECAB with BITA to the LAD and OM branches, with planned staged PCI to the RCA.Under general anesthesia, the patient was positioned supine. Due to intolerance of single-lung ventilation, the procedure was performed with intermittent bilateral lung ventilation. Robotic ports were placed in standard left thoracic positions. Both ITAs were harvested in skeletonized fashion. The LITA was anastomosed to the LAD and the RITA to the OM branch using running 7-0 Prolene sutures and 1.5 mm shunts. After the first anastomosis, the patient developed ventricular fibrillation—likely from reperfusion injury—requiring ACLS, defibrillation, and placement of a femoral intra-aortic balloon pump. Sinus rhythm was restored, and reassessment revealed no deterioration in cardiac function. EF improved to 50% by the end of the case. The robot was re-docked, and the second graft was completed.
RESULTS: Both grafts demonstrated excellent flow. Hemostasis was achieved, bilateral chest drains were placed, and the patient was extubated the same evening. He was transferred to the floor on postoperative day 1 and discharged home on day 4. At four-week follow-up, the patient reported complete resolution of dyspnea and significantly improved functional status.
CONCLUSIONS: This case highlights the feasibility of robotic BITA TECAB in patients with prohibitive surgical risk. With appropriate expertise and intraoperative adaptability, robotic revascularization can be safely completed even in the face of acute intraoperative instability.
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