1  2005 European Association for Cardio-thoracic Surgery doi:10.1510/mmcts.2004.000778 Left anterior small thoracotomy procedure Gabriele Di Giammarco*, Marco Pano, Marco Contini, Piero Pelini, Alessandro Di Francesco, Marco Valente, Michele Di Mauro Division of Cardiac Surgery, University ‘‘G. D’Annunzio’’, S. Camillo de Lellis Hospital, via Forlanini 50, 66100 Chieti, Italy The left anterior descending (LAD) artery off-pump grafting with the left internal mammary artery (LIMA), via a left anterior small thoracotomy (LAST operation) introduced, for the first time, by Vasilii Kolesov in 1964, gained popularity in the second half of the 1990s. Patients with single LAD disease (not suitable for interventional treatment) or patients showing multi- vessel disease with the other coronaries occluded and refilled by collateral circulation, but not graftable because of technical issues, can be considered candidates for this type of operation. The incision is performed at the 4th intercostal space. Pectoralis and intercostal muscles are dissected and the pericardium is opened. The LIMA is harvested as a pedicle up to the clavicle to reach a more distal and/or more lateral anastomotical site. After the stabilizer has been positioned, the LAD is incised and an intracoronary shunt is inserted. The anastomosis is then performed on a beating heart. Finally, the anastomosis is checked by means of a transit-time flowmeter. The intercostal space is then closed in a standard fashion, leaving a drainage inside. In our experience, 853 patients underwent the LAST operation. Early mortality rate was 1.2% with a nine-year survival of 91.3"1.0. Keywords: Left anterior descending (LAD); Left anterior small thoracotomy (LAST); Left internal mammary artery (LIMA) Introduction History Off-pump left anterior descending (LAD) grafting using left internal mammary artery (LIMA), via a standard left anterior thoracotomy, was introduced for the first time in 1964 by Vasilii Kolesov w1x. It has been an isolated experience until the 1990s, when a group of surgeons called Benetti, Acuff, Rob- inson, Subramanian and Calafiore w2–6x reproposed the same procedure with only a few modifications. The most important being a minimal invasive access * Corresponding author: Tel.: q39-087-135 8628; fax: q39-087-135 7552. E-mail: gabriele.digiammarco1@tin.it (left anterior small thoracotomy, LAST operation). The possibility to revascularize the most important coro- nary artery, using the most important arterial conduit w7x, generated a great deal of interest, even if some concerns about technical aspects and midterm results have been overcome only in the second half of the 1990s, with the advent of different stabilization systems w8x and the publication of fairly good midterm results w9x. Surgical indications Candidates for the LAST operation are patients with the following characteristics: Patient with single LAD disease 1. Percutaneous transluminal coronary angioplasty (PTCA) not feasible because of technical aspects.