Ann Thorac Surg 1998;65:861-862
© 1998 The Society of Thoracic Surgeons
How to Do It
Method for Creation of the Aortotomy Site for Saphenous Vein Grafts
John C. Alexander, Jr, MD,
Timothy V. Votapka, MD,
Ronald D. Curran, MD,
James M. Unger, PA-C,
Neal D. Hillman, MD
Division of Cardiothoracic Surgery, Evanston Hospital and Northwestern University Medical School, Evanston, Illinois, USA
Accepted for publication October 14, 1997.
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Abstract
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Saphenous vein coronary artery bypass grafting requires a proximal anastomosis of the vein to the aorta. A variety of techniques have been described to create the aortotomy. We have developed a four-sided knife (Xcision Scalpel; patent pending, Research Medical, Inc, Midvale, UT) that facilitates the creation of a more uniform circular aortotomy. The purpose of this communication is to describe the knife and the technique for its use.
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Introduction
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Currently, most aortotomies used for bypass grafts are created using an aortic punch. There are a number of punches available, but all require a small incision to be made in the aorta through which the punch is inserted. After the anvil of the punch is introduced through the aortic incision, the punch is centered, engaged, and fired, creating a circular aortotomy. To get the anvil of the punch into the aorta, the surgeon must make the incision longer than the diameter of the anvil or the aorta must be stretched. When the incision is longer than the punch anvil diameter, lateral nicks in the circumference of the aortotomy are created (Fig 1). This necessitates either repunching the aorta, excising the lateral nicks, and enlarging the aortotomy or placing the sutures in a manner to ensure that bleeding does not occur at these lateral linear nicks. We have also used a dilator before inserting the punch to enlarge the initial linear incision. Using the dilator we have encountered irregular and unpredictable tearing of the aorta. The brittle and fragile nature of the aorta in the average patient undergoing coronary artery bypass grafting necessitates great care in dealing with the aortic wall. These problems with punch aortotomies, although relatively minor, can at times result in major complications of bleeding, compromise of the proximal vein anastomosis, or aortic dissection.
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Standard linear incision made in the aorta for insertion of the aortic punch. The dashed circle is the footprint of the anvil of the aortic punch when placed inside the aorta. The insert demonstrates the aorta after the punch has been used to create the aortotomy. Note the lateral side notches.
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Technique
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In conjunction with Research Medical Inc (Midvale, UT) we have developed a four-sided knife (Xcision Scalpel) to create the initial aortic incision. The knife is similar in design to an 11 blade except that it is made in a four-sided configuration with four perpendicular cutting surfaces. The knife creates an incision in the aorta at the site of the planned aortotomy (Fig 2). The knife width is slightly smaller than the diameter of the punch anvil with which it is used (Fig 3). During punch insertion, the aorta is displaced in four directions rather than two, making insertion of the anvil easier and less traumatic to the aortic wall. Once the anvil of the punch is inserted, the shaft of the punch is centered and the punch is fired. We have found that aortotomy punch sites created in this manner are more uniform and circular and linear side notches are less frequent.
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The four-sided knife with the four cutting surfaces arranged at 90 degrees from each other. Insertion of the four-sided knife creates a cruciate incision in the aorta.
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The four-sided cruciate incision is slightly smaller than the anvil of the punch. The insert demonstrates the completed circular aortotomy without the lateral side cuts.
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We believe this knife significantly improves our ability to create the proximal anastomotic site. We usually perform the distal vein to coronary anastomosis first. The vein graft is then cut to the appropriate length while antegrade cardioplegia is being given into the aortic root to fill and pressurize the aorta. We select the proximal anastomotic site and remove the aortic adventitia. The Xcision Scalpel is then passed perpendicular into the aorta, creating a cruciate incision in the aorta. The punch is placed through the cruciate incision, centered, and fired. The proper use of this knife requires the same care to avoid injuring the back wall of the aorta that any aortic incision demands. The proximal anastomosis is then created in the standard fashion.
The knife is disposable and relatively inexpensive. Its sharpness is comparable with that of a standard 11 blade. We have used this knife successfully in more than 100 aortotomies without complications.
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F. D. Rubens, M. Boodhwani, T. Mesana, D. Wozny, G. Wells, H. J. Nathan, and on behalf of the Cardiotomy Investigators
The Cardiotomy Trial: A Randomized, Double-Blind Study to Assess the Effect of Processing of Shed Blood During Cardiopulmonary Bypass on Transfusion and Neurocognitive Function
Circulation,
September 11, 2007;
116(11_suppl):
I-89 - I-97.
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Abstract
Introduction
