Treatment of Coronary Artery Disease with Minimally Invasive (Closed) Bypass

When coronary bypass is mentioned, what still comes to mind most of the time is the classic operation in which the breastbone is opened right down the middle, leaving a large incision scar. Yet in the suitable patient we can today perform this operation without touching the breastbone at all, through a small incision made between the ribs. The general comparison between stenting (percutaneous coronary intervention) and open bypass surgery with sternotomy in coronary artery disease, and the causes of coronary artery disease, are the subjects of other articles. In this article I will address directly the minimally invasive, that is closed, bypass techniques and the patients in whom we prefer them.

What Is Closed Bypass, and How Does It Differ from Open Surgery?

In classic open bypass we open the whole breastbone (sternotomy); we can reach the heart comfortably from every direction, but this means both a greater surgical trauma and a longer recovery process. In closed bypass, on the other hand, it is just like reaching a car’s engine through a small service hatch instead of opening the whole bonnet; we reach the heart through an incision of a few centimetres made between the ribs on the left side of the chest. In this approach we carefully prepare the mammary artery on the inner surface of the chest (LIMA) and, if necessary without stopping the heart, we suture it directly to the blocked vessel while the heart is beating.

Which Technique for Whom? Our Decision Criteria

We can now perform closed bypass in complex and widespread disease involving more than one vessel as well. Even so, for reasons such as excess weight or unsuitable anatomy, we may need to consider classic open surgery or a hybrid approach combining closed bypass with stenting. A history of previous lung, chest or heart surgery and the state of heart function also directly affect this decision.

Treatment Options

MIDCAB (Direct Bypass Through a Small Incision): Through a small incision made between the ribs, we can bypass all the vessels using the mammary artery. We all know that bypass operations performed with the mammary artery increase expected survival and reduce adverse events compared with all stent procedures. MIDCAB is the closed bypass technique we apply most often. With this technique we can, where necessary, also carry out the bypass operation without stopping the heart. Robotically Assisted Bypass: By means of robotic arms we prepare the mammary artery through much smaller openings and complete the anastomosis (the vessel suture) through a small incision; thanks to the precision of movement and the magnification of the image, we obtain a very delicate working field. Totally Endoscopic Bypass (TECAB): In suitable and experienced centres we complete the entire procedure with robotic arms through millimetric openings, while the heart is beating or with it stopped for a short period; this is the most advanced point of the closed techniques. Hybrid Revascularisation: In disease involving more than one vessel, we bypass the most important vessel of the heart (the LAD) with a closed procedure using the mammary artery, and treat the other vessels with stents in the same or a separate session, thus offering the patient the advantages of both methods together.

The Advantages of Closed Bypass — What Does the Literature Say?

Large reviews and meta-analyses examining closed and robotic bypass show that these techniques can be applied safely with low perioperative mortality and complication rates, that the rate of conversion to open surgery remains below 3%, and that graft patency rates remain quite high in follow-up periods averaging more than 5 years. In studies comparing closed bypass with stenting in LAD disease in particular, the need for repeat intervention over the long term has been reported to be lower in those who had bypass; the main reason for this is that the mammary artery remains open for far longer than stents. Because the incision is small, blood loss, the need for blood transfusion and the risk of infection are also markedly reduced compared with open surgery.

The Post-Procedure Period

After closed bypass we monitor our patients in intensive care for a short period; because the breastbone is not opened, the level of pain is markedly lower and we discharge most of our patients within 4-5 days. Since it does not require a sternotomy (opening the breastbone), there is no need to wait for bone healing, and this markedly speeds the return to daily activities and to work compared with classic open surgery. Patients do not have to wear a corset for months, are not obliged to lie on their back, can use their arms as they wish, and can cough and sneeze comfortably without the fear of moving the bone. After discharge we continue to monitor both the patency of the grafts and the overall function of the heart with regular check-ups.

Frequently Asked Questions

Can closed bypass be applied to every patient? No. The most suitable candidates are patients whose disease is limited to the left anterior descending artery (LAD) or in whom this vessel is dominant. Those who have previously had heart or lung surgery, those whose lungs are adherent to the chest wall, and people with anatomical variations may not be suitable for closed bypass.

What makes closed bypass different from a stent? A stent is a device placed inside the vessel; in bypass, on the other hand, a new route beyond the blocked segment is created with the patient’s own vessel. Especially when the mammary artery (LIMA) is used, the long-term patency rate of this new route is very high.

Is surgery without stopping the heart safe? Yes. Beating-heart bypass (off-pump) is a method that is applied safely in experienced hands and completely eliminates the time spent connected to the heart-lung machine. In some patients this method has its advantages.

What is the difference between robotic bypass and classic closed bypass? In the robotic technique the arms move through much smaller openings and provide the surgeon with a magnified, three-dimensional image; this offers extra precision especially in the preparation of the mammary artery.

Conclusion

In coronary artery disease, closed/minimally invasive bypass is a technique that offers a lasting solution in the right patient with the heart’s most reliable graft, without opening the breastbone. Across this range of options, extending from MIDCAB to robotically assisted bypass and from totally endoscopic techniques to hybrid revascularisation, our aim is always the same: to obtain the most durable result with the least surgical trauma.

You can book an appointment for a detailed examination so that we can assess which option is suitable for you for your coronary artery disease.

References

1. Bonatti J, Wallner S, Crailsheim I, Grabenwöger M, Winkler B. Minimally Invasive and Robotic Coronary Artery Bypass Grafting: A 25-Year Review. J Thorac Dis. 2021;13(3):1922-1944.
2. Hwang B, Ren J, Wang K, Williams ML, Yan TD. Systematic Review and Meta-Analysis of Two Decades of Reported Outcomes for Robotic Coronary Artery Bypass Grafting. Ann Cardiothorac Surg. 2024;13(4):311-325.
3. Gianoli M, de Jong AR, Jacob KA, et al. Minimally Invasive Surgery or Stenting for Left Anterior Descending Artery Disease – Meta-analysis. Int J Cardiol Heart Vasc. 2022;40:101046.
4. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on Myocardial Revascularization. Eur Heart J. 2019;40(2):87-165.