27 CASE REPORT First total coronary revascularization via left anterior thoracotomy Copyright (c) 2025 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. First total coronary revascularization via left anterior thoracotomy – TCRAT in Slovenia Prva popolna revaskularizacija miokarda skozi levo sprednjo torakotomijo v Sloveniji Arta Krasniqi, Boris Robič, Peter Jurič, Miha Antonič Abstract Total coronary revascularization via left anterior thoracotomy presents a less invasive alternative to traditional coronary artery bypass grafting for complex coronary artery disease. It combines the benefits of minimally invasive surgery with a simplified approach, making it a promising option for surgical coronary artery disease management. In this report, we present the first case of a total coronary revascularization via left anterior thoracotomy performed in Slovenia, involving a 56-year-old patient with symptomatic two-vessel coronary artery disease. Izvleček Koronarna revaskularizacija skozi levo sprednjo torakotomijo je manj invazivna alternativna možnost tradicionalni reva- skularizaciji koronarnih arterij pri kompleksni koronarni bolezni. Povezuje prednosti minimalno invazivne kirurgije s po- enostavljenim pristopom in obeta učinkovit ter varen način kirurškega zdravljenja koronarne bolezni. Prispevek poroča o prvi popolni koronarni revaskularizaciji srca skozi levo sprednjo torakotomijo v Sloveniji, ki smo jo opravili pri 56-letnem bolniku z dvožilno koronarno boleznijo s simptomi. Clinical Department of Cardiovascular Surgery, University Medical Centre Maribor, Maribor, Slovenia Correspondence / Korespondenca: Arta Krasniqi, e: artakrasniqi.dr@gmail.com Keywords: myocardial revascularization; thoracotomy; minimally invasive surgery; coronary artery bypass surgery Ključne besede: kirurška revaskularizacija miokarda; torakotomija; minimalno invazivna kardiokirurgija; kirurški obvodi koronarnih arterij Received / Prispelo: 14. 5. 2024 | Accepted / Sprejeto: 7. 1. 2025 Cite as / Citirajte kot: Krasniqi A, Robič B, Jurič P, Antonič M. First total coronary revascularization via left anterior thoracotomy – TCRAT in Slovenia. Zdrav Vestn. 2025;94(1–2):27–31. DOI: https://doi.org/10.6016/ZdravVestn.3545 eng slo element en article-lang 10.6016/ZdravVestn.3545 doi 14.5.2024 date-received 7.1.2025 date-accepted Cardiovascular system Srce in obtočila discipline Case report Klinični primer article-type First total coronary revascularization via left anterior thoracotomy – TCRAT in Slovenia Prva popolna revaskularizacija miokarda skozi levo sprednjo torakotomijo v Sloveniji article-title First total coronary revascularization via left anterior thoracotomy Prva popolna revaskularizacija miokarda skozi levo sprednjo torakotomijo v Sloveniji alt-title myocardial revascularization, thoracotomy, minimally invasive surgery, coronary artery bypass surgery kirurška revaskularizacija miokarda, torakotomi- ja, minimalno invazivna kardiokirurgija, kirurški obvodi koronarnih arterij kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2025 94 1 2 27 31 name surname aff email Arta Krasniqi 1 artakrasniqi.dr@gmail.com name surname aff Boris Robič 1 Peter Jurič 1 Miha Antonič 1 eng slo aff-id Clinical Department of Cardiovascular Surgery, University Medical Centre Maribor, Maribor, Slovenia Klinični oddelek za kardiokirurgijo, Univerzitetni klinični center Maribor, Maribor, Slovenija 1 Slovenian Medical Journallovenian Medical Journal 28 CARDIOVASCULAR SYSTEM Zdrav Vestn | January – February 2025 | Volume 94 | https://doi.org/10.6016/ZdravVestn.3545 1 Introduction Coronary artery bypass grafting (CABG) via ster- notomy is widely considered the gold standard for myocardial revascularization in multivessel coronary artery disease (CAD) (1,2). However, the invasive na- ture of traditional CABG, particularly the full sternot- omy approach, often leads to decreased physical func- tioning and potential complications, such as sternal dehiscence and deep sternal wound infection (3). The associated invasiveness, especially the physical debil- itation and reduced quality of life resulting from full sternotomy, underscores the need for less traumatic alternatives. In 2019, a less invasive alternative, total coronary revascularization via left anterior thoracoto- my (TCRAT), was proposed (4). Although minimally invasive techniques such as robotic endoscopic CABG or minimally invasive cardiac surgery (MICS) offer reduced invasiveness, their adoption remains limited due to procedural complexity and infrastructure re- quirements (5-7). The emergence of TCRAT over the last five years presents a promising alternative, allow- ing complete revascularization without midline ster- notomy. Despite its growing adoption, cases of TCRAT in Slovenia have not been previously reported. We introduced this minimally invasive technique to our clinic, and we report our first experience with TCRAT performed on a 56-year-old patient. 2 Case presentation A 56-year-old male with symptomatic CAD was admitted for expedited surgical coronary revascular- ization. Despite optimal medical management, includ- ing treatment for ischemic heart disease, a previous silent myocardial infarction, arterial hypertension, and hypercholesterolemia, the patient continued to experience angina symptoms necessitating surgical intervention. Preoperative assessment, including cor- onary angiography, revealed severe multivessel CAD, prompting the need for total coronary revasculariza- tion (Figure 1). The TCRAT procedure has been thoroughly de- scribed in detail elsewhere (4). In summary, following a standard anesthesia protocol, right-sided single-lung ventilation was initiated using a bronchial blocker. Subsequently, a left-sided mini-thoracotomy incision was made through the fourth intercostal space (Figure 2A). The left internal mammary artery (LIMA) was harvested through the left mini-thoracotomy using a ThoraGateTM rib-up retractor (Geister Medizintech- nik, Tuttlingen, Germany) through the 4th intercos- tal space. A skeletonized technique was utilized using electrocautery and vascular clips. Concurrently, an as- sistant harvested a saphenous vein from the patient’s left leg. Following appropriate heparinization, pe- ripheral arterial and venous femoral cannulation was performed using transesophageal echography (TEE) guidance. The cannula for antegrade cardioplegia was placed in the ascending aorta. Subsequently, extracor- poreal circulation was initiated. During this time, both the LIMA and vein were prepared. The ascending aor- ta was clamped with adequate perfusion using a Chit- wood (Scanlan International Inc, St. Paul, MN, USA) clamp through a separate 1-cm incision in the left 2nd intercostal space. The heart was then arrested using cold blood antegrade cardioplegia, repeated approxi- mately every 10 minutes. Then, three nylon tapes were placed around the aortic root (Ao), left pulmonary veins (PV), and inferior vena cava (IVC) (Figure 2B). Figure 1: Preoperative coronary angiography showing the stenosis of left anterior descending (LAD), diagonal (D1) and chronic total occlusion (CTO) of ramus intermedius (rIM). Source: archive of the Clinical Department of Cardiovascular Surgery, University Medical Centre Maribor. 29 CASE REPORT First total coronary revascularization via left anterior thoracotomy The three target coronary arteries were exposed for distal anastomoses by manipulating the nylon tapes. First, the distal anastomosis on the ramus intermedius artery (rIM) was created, followed by a sequential anas- tomosis of LIMA to LAD and D1. After completion of the distal anastomoses, the aortic clamp was released, and a side clamp was placed on the ascending aorta. A spontaneous cardiac rhythm was restored. With the manipulation of the nylon tape and the side clamp, the ascending aorta was put in the optimal position for proximal anastomoses construction. One proximal venous anastomosis was constructed, one in the place of the antegrade cardioplegia catheter. After comple- tion of the proximal anastomosis, the side clamp was released. All anastomoses were inspected, and the pa- tient was gradually weaned off the extracorporeal cir- culation. Heparin was neutralized with protamine, and the patient was decannulated. Flow through the cardi- ac bypass grafts was verified using a transit time flow meter (Medistim, Oslo, Norway) probe. Hemostasis was meticulously achieved, and the chest opening was closed in layers, with a thoracic drain placed in the left pleural cavity. (Figure 3). 3 Outcome Postoperatively, the patient was transferred to the Cardiac Surgery Perioperative Intensive Care Unit for monitoring. Serial assessments, including hemo- dynamic monitoring, cardiac enzyme measurements, and echocardiography, revealed satisfactory recovery without evidence of myocardial ischemia, rhythm disturbances, or hemodynamic instability. Following successful extubating and stabilization, the patient was transferred to the ward. The postoperative course was uneventful, and the patient was discharged home on the fifth postoperative day. 4 Discussion The case presented herein highlights the utilization of TCRAT as a less invasive alternative to standard CABG through median sternotomy. Median sternotomy can lead to severe complica- tions, including sternal wound infections, sternal de- hiscence, and extended recovery periods. Studies have demonstrated that patients undergoing sternotomy experience significant reductions in health-related quality of life and functional capacity postoperatively (4). To mitigate these risks, minimally invasive ster- num-sparing techniques have been developed and are now widely adopted in various fields of cardiac surgery, such as those involving the aortic and mitral valves, and treatments for atrial fibrillation. However, these advancements have not yet become prevalent in coronary revascularization surgery. While CABG remains the gold standard for myo- cardial revascularization in multivessel CAD, the as- sociated morbidity and impaired quality of life due to sternotomy incisions have driven the exploration of less invasive approaches, such as TCRAT (1). The selection criteria for TCRAT involve a Figure 2: Chest opening for coronary revascularization through left anterior thoracotomy (A) and tapes for exposure of coronary vessels (B). Source: archive of the Clinical Department of Cardiovascular Surgery, University Medical Centre Maribor. Figure 3: Postoperative incision on our 56-old male patient. Source: archive of the Clinical Department of Cardiovascular Surgery, University Medical Centre Maribor. 30 CARDIOVASCULAR SYSTEM Zdrav Vestn | January – February 2025 | Volume 94 | https://doi.org/10.6016/ZdravVestn.3545 combination of anatomical, clinical, and patient-spe- cific factors. TCRAT is particularly suitable for patients with limited coronary disease, such as lesions in the LAD, D1, or rIM, where only a limited number of ves- sels need revascularization. However, in experienced hands, complex multivessel disease is not a contrain- dication for TCRAT. Additionally, TCRAT is beneficial for patients with comorbidities like obesity, diabetes, or chronic obstructive pulmonary disease, which ele- vates the risks of traditional sternotomy. Patients seek- ing a minimally invasive approach with faster recovery and smaller incisions are often ideal candidates. The procedure also requires that target coronary vessels are of adequate size and quality, and patients should be in stable health to tolerate the demands of the technique. Careful selection is crucial to ensure that TCRAT is the optimal choice for patients with coronary disease. The benefits of TCRAT lie in its potential to mitigate the drawbacks associated with conventional CABG, primarily stemming from midline sternotomy. The introduction of TCRAT offers a promising solution to address these concerns by providing a less invasive sur- gical option. Existing literature on minimally invasive techniques, including robotic endoscopic CABG and hybrid procedures, has shown promising outcomes in terms of reduced invasiveness and improved patient recovery (5-7). However, these approaches have faced challenges in widespread adoption due to procedural complexity and infrastructure requirements, which are usually associated with high financial costs. TCRAT presents an alternative that combines the benefits of minimally invasive surgery with a simplified surgical approach, potentially overcoming some of the barriers to adoption encountered by other techniques. While TCRAT offers significant advantages in se- lect patient populations, it also has notable limitations in certain clinical scenarios. One key challenge arises in redo-procedures involving patients with prior ster- notomy or chest surgeries. In these cases, fibrous ad- hesions of the pericardium can severely restrict heart mobility, significantly complicating the procedure. Similarly, adhesions of the left pleura, often result- ing from prior left lung surgeries, can make mamma- ry grafting particularly difficult. Altered anatomy may further impede access to the mammary artery and cor- onary vessels via a left anterior thoracotomy, increas- ing the risk of injury to surrounding structures and reducing the efficacy of the approach. Thoracic deformities, such as those associated with Marfan syndrome or severe scoliosis, can distort the rib cage and sternum, complicating surgical exposure. These conditions may also alter the positioning and mobility of the heart, further challenging the surgical field. Although TCRAT is not contraindicated in patients requiring bilateral internal mammary artery grafts, it requires a specialized retractor to facilitate harvesting of the right internal mammary artery through the left anterior mini-thoracotomy. Severe peripheral arterial disease can preclude pe- ripheral cannulation. Similarly, extensive atheroscle- rotic involvement of the ascending aorta may compli- cate the procedure due to the increased manipulation of the aorta during surgery and the need for addition- al aortic side-clamping during proximal anastomosis construction. Furthermore, TCRAT is less suitable for emergency cases or unstable patients, where rapid ini- tiation of cardiopulmonary bypass and immediate re- vascularization are critical and cannot tolerate delays. These challenges emphasize the importance of thorough preoperative evaluation and tailored surgical planning to determine the most appropriate revascu- larization strategy for patients with complex anatomi- cal or clinical conditions. In the context of the presented case, the successful application of TCRAT in a 56-year-old male patient with symptomatic CAD demonstrates its feasibility and efficacy as an alternative to traditional sternotomy. De- spite the patient’s medical history, including previous myocardial infarction, TCRAT was performed with- out intraoperative complications, leading to excellent postoperative outcomes. This case adds to the growing body of evidence supporting the use of TCRAT in pa- tients with CAD, particularly those who may be at a high risk of developing serious complications linked to median sternotomy. Future studies and long-term follow-up are war- ranted to further evaluate the long-term safety, effica- cy, and durability of TCRAT compared to traditional CABG and other minimally invasive techniques. Addi- tionally, comparative studies assessing outcomes such as mortality, morbidity, and quality of life between different surgical approaches will provide valuable in- sights into the optimal management of patients with CAD. In conclusion, the successful performance of TCRAT in this case underscores its potential as a min- imally invasive alternative to traditional CABG in pa- tients with CAD. However, while TCRAT represents a promising alternative to traditional median sternot- omy for coronary revascularization, its applicability is not without limitations. Careful patient selection, 31 CASE REPORT First total coronary revascularization via left anterior thoracotomy including consideration of anatomical factors, comor- bidities, and the complexity of the coronary disease, is essential to ensure optimal outcomes. As the technique continues to evolve, further studies and long-term fol- low-up are necessary to refine its indications and as- sess its comparative effectiveness in various clinical scenarios. 5 Conclusion Our experience with the first reported case of TCRAT in Slovenia demonstrates its feasibility and efficacy as an alternative to traditional sternotomy for total coronary revascularization in selected patients with complex CAD. This minimally invasive approach offers the potential for favorable postoperative out- comes and enhanced quality of life. Further studies are warranted to assess its long-term safety and effective- ness in a broader patient population. Conflict of interest None declared. Informed consent of the patient The patient gave informed consent for the publica- tion of his case. References 1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. DOI: 10.1093/eurheartj/ehy394 PMID: 30165437 2. Sipahi I, Akay MH, Dagdelen S, Blitz A, Alhan C. Coronary artery bypass grafting vs percutaneous coronary intervention and long-term mortality and morbidity in multivessel disease: meta-analysis of randomized clinical trials of the arterial grafting and stenting era. JAMA Intern Med. 2014;174(2):223-30. DOI: 10.1001/jamainternmed.2013.12844 PMID: 24296767 3. Järvinen O, Saarinen T, Julkunen J, Huhtala H, Tarkka MR. Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2003;24(5):750-6. DOI: 10.1016/S1010-7940(03)00413-5 PMID: 14583308 4. Babliak O, Demianenko V, Melnyk Y, Revenko K, Pidgayna L, Stohov O. Complete Coronary Revascularization via Left Anterior Thoracotomy. Innovations (Phila). 2019;14(4):330-41. DOI: 10.1177/1556984519849126 PMID: 31106625 5. Bonaros N, Schachner T, Lehr E, Kofler M, Wiedemann D, Hong P, et al. Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety. Ann Thorac Surg. 2013;95(3):803-12. DOI: 10.1016/j.athoracsur.2012.09.071 PMID: 23312792 6. 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):1922-44. DOI: 10.21037/jtd-20-1535 PMID: 33841980 7. Sellin C, Asch S, Belmenai A, Mourad F, Voss M, Dörge H. Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy. Thorac Cardiovasc Surg. 2023;71(6):448-54. DOI: 10.1055/s-0042-1758149 PMID: 36368676