Robotic Surgery-stenting Combo Opens Coronary Arteries, Speeds Recovery

"The minimally invasive procedure effectively bypassed or opened blocked arteries in all 27 patients, an outcome as good or better than you would expect with open chest surgery," said Marc R. Katz, M.D., lead author of the study and chief of cardiac surgery and director of the Virginia Transplant Center at Henrico Doctors' Hospital in Richmond.

"The patients stayed in the hospital an average of only two and a half days, compared with five or six days for conventional CABG surgery," Katz said. "And they were back to work in a week or so, compared with the usual six to 12 weeks."

The study involved patients with multi-vessel coronary disease, including obstruction of the left anterior descending coronary artery (LAD), the main artery in the front of the heart.

During the closed-chest bypass procedure, the left internal mammary artery (in the chest) was harvested. Doctors then sutured the mammary artery to the obstructed LAD, bypassing the obstruction, all done endoscopically.

During the angioplasty procedure, doctors used stents (mesh tubes) to unblock other arteries and then prop them open.

"Using the left internal mammary artery to bypass the LAD is the one thing we can do for patients with coronary artery disease that has a proven survival advantage," Katz said. "Here is a way to accomplish that and also open other vessels in a very minimally invasive way."

Robotic surgery involves making three small incisions, each about 1 cm (½ inch) long, in the left side of the patient's chest. A 3-D scope with 10x magnification is inserted in the middle port, with the robotic right and left arms in the other ports. The daVinci robotic system is a powerful computer interface that allows surgeons to sit at a console with full vision of the operative field. The surgeon's usual surgical hand movements are translated through the miniature robotic arms inside the patient. The robotic arms, with interchangeable instruments at their tips, precisely follow the surgeon's hand movements.

"Robotic surgery is much less invasive than regular CABG operations, and patients recover much more quickly with less pain, less scarring and less disability," Katz said.

The study included 27 patients who averaged 59 years old. All had fatty deposits narrowing the heart's main arteries, including obstructions in the LAD that precluded treatment with angioplasty.

Eleven patients had angioplasty an average of 38 days prior to their bypass operation; 12 patients had angioplasty an average of 16 days after surgery; and four patients had simultaneous procedures.

Ten patients got bare-metal stents; 17 received stents coated with a time-release drug to reduce the risk of re-narrowing.

Patients had a follow-up angiogram three months after the surgical procedure. Twenty-six of the 27 had wide-open bypass grafts, only one patient had a narrowing at the site where the graft had been sewn into the coronary artery. This was easily opened with a balloon.

Two-thirds of the stented segments also were unobstructed, with one-third showing re-narrowing. These nine patients underwent a second procedure to re-open their arteries.

The procedure was extremely safe, and no patients died.

Co-authors include Frank Van Praet, M.D.; Didier de Canniere, M.D., Ph.D; Douglas Murphy, M.D.; Leland Siwek, M.D.; Sudir Srivastava, M.D.; Usha Kreaden, M.Sc.; and Johannes Bonatti, M.D. Intuitive Surgical funded the study.