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Multi–Detector Row CT versus Coronary Angiography: Preoperative Evaluation before Totally Endoscopic Coronary Artery Bypass Grafting¹

¹ From the Institute for Diagnostic and Interventional Radiology (C.H., T.D., T.J.V.) and Departments of Thoracic and Cardiovascular Surgery (S.D., M.F.K., G.W.G., A.M.) and Epidemiology and Medical Statistics (H.A.), J. W. Goethe-University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany; and CT Division, Siemens Medical, Forchheim, Germany (S.S., T.G.F.). Received May 29, 2002; revision requested July 26; final revision received December 17; accepted January 14, 2003. Address correspondence to C.H. (e-mail: c.herzog@em.uni-frankfurt.de).

View larger version (170K): [in a new window]   Figure 1. Schematic drawing, view from above, shows the intraoperative setting of a TECAB procedure. Surgeon sits in front of a console (1), allowing three-dimensional endoscopic visualization of the intraoperative field, and telemanipulates the robot (2) with scissors-like handles. Robot consists of three swivel arms, one carrying the camera and two holding the surgical instruments. Perioperative monitoring is provided by the anesthesiologist (3). Though most of all TECAB procedures are performed with assistance of a heart-lung machine (4), the latest technical developments also render possible the performance of procedures on the beating heart.

View larger version (185K): [in a new window]   Figure 2. Left anterior oblique images show four steps of TECAB procedure. Black arrows point to the coronary artery, and white arrows mark the bypass graft. After dissection of epicardium, the surgeon first identifies the relevant cardiac structures. Top left: Epicardial fatty tissue (F) is observed, and often it prevents direct visualization of the target vessel. Top right: Without further morphologic information, only careful dissection of the fatty tissue allows exact localization of the position of the vessel. Bottom left: Target vessel is incised with a distance of 6-7 mm. Bottom right: Target vessel is grafted in an end-to-side technique with the left internal mammary artery that previously was mobilized from the chest wall.

View larger version (85K): [in a new window]   Figure 3. Left: Mirror-inverted 15° right anterior oblique invasive angiogram. Right: Left anterior oblique multi-detector row CT scan. Both techniques correctly depicted the 100% stenosis (arrowhead) within segment 6 of the LCA, but only multi-detector row CT revealed the marked calcifications of segment 7 of the LCA (arrows), rendering bypass grafting in this region difficult. With this information, the surgical access was adapted to reach the more distal segment 8, and bypass grafting was performed successfully. D1 = first diagonal branch, LCX = left circumflex artery, M1 = first marginal branch.

View larger version (152K): [in a new window]   Figure 4. Top: Mirror-inverted 15° right anterior oblique invasive angiograms. Bottom: Left anterior oblique multi-detector row CT scans. Both techniques correctly depicted the 80% stenosis (arrowhead) within segment 6 of the LCA, but only multi-detector row CT revealed the intramural course of segment 7 of the LCA (arrows). With this information, the surgical access was altered to reach the more distal segment 8, and bypass grafting was performed successfully. Note the vein (V) that accompanies the intramural course of the LCA on the myocardial surface. D1 = first diagonal branch, LCX = left circumflex artery, M1 = first marginal branch.

View larger version (80K): [in a new window]   Figure 5. Left: Mirror-inverted 15° right anterior oblique invasive angiogram. Right: Left anterior oblique multi-detector row CT scan. Images show how different coronary segments may easily be confused because of restricted field of view and lack of manual palpation during TECAB procedures. The patient (same as for Fig 2) has a large first diagonal branch (D1) that courses nearly parallel to the LCA. Both vessels are hidden deep inside the epicardial fat (compare Fig 2), and the LCA additionally nestles against the pulmonary trunk. In cases such as this, accidental grafting of diagonal branch 1 is a common risk. Three-dimensional multi-detector row CT reformations provided additional morphologic information in regard to surrounding structures and helped the surgeon to gain a better orientation. LCX = left circumflex artery, M1 = first marginal branch.