Ann Thorac Surg 1998;66:966-967
© 1998 The Society of Thoracic Surgeons
How to Do It
Accurate length adjustment of aortocoronary saphenous vein bypass grafts
Aurangzeb Durrani, FRCSa,
Eugene K.W. Sim, FRCSa,
Robert T. Grignani, IBDipa
a Cardiac Department, National University Hospital, Singapore
Accepted for publication May 23, 1998.
Address reprint requests to Dr Sim, Cardiac Department, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
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Abstract
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We describe a simple method for tailoring the length of aortocoronary saphenous vein grafts. The objective is to prevent any kinking of the these grafts, which may compromise blood flow in them and lead to their early occlusion.
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Introduction
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One of the most important aspects of the aortocoronary bypass graft operation is accurate adjustment of the length of the grafts. Too short a length might cause tension on the graft, whereas too long a length might cause kinking. Both of these situations may lead to compromise in the blood flow in these grafts [1]. In our unit we have devised a simple method to accurately adjust the lengths of saphenous vein bypass grafts, to the left-sided as well as the right-sided systems, for grafts that are too long and are kinking as the sternal edges are brought together.
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Technique
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After it is established that the grafts are too long, which usually becomes apparent as the sternal retractor is taken out and the sternal edges come together, a separate strategy is employed for the left- and right-sided grafts. For grafts to the obtuse marginal, ramus intermedius, or diagonal branches, a flap of extrapericardial fat and thymic remnant is raised, which is pedicled superiorly (Fig 1). After the flap of fat is checked for bleeding, it is tucked under the saphenous vein grafts where they curve over the pulmonary artery. This eliminates the kink and makes them lie in a perfect curve over the pulmonary artery (Fig 2). Finally 1 mL of tissue glue is squirted over these grafts to secure them to the fat pedicle.
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Fig 2. The pad of fat is pedicled superiorly and tucked under the left-sided grafts, making them lie in a smooth curve.
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For grafts to the distal right coronary artery or posterior descending artery, we usually cut two vertical slits into the pericardium with diathermy, taking care to avoid the phrenic nerve. The slits in the pericardium now look like a wide W (Fig 3). The saphenous vein graft is hooked over this W as shown in Figure 4, and 1 mL of tissue glue secures it in place. This makes it lie in a nice curve without kinks.
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Fig 4. The right-sided vein graft as it is positioned finally, threaded through the pericardial incisions. Note that the phrenic nerve has been conserved on the right side.
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In our experience, we have had no problems with these techniques. They have worked very well for us whenever the problem of too long a graft length has arisen.
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Comment
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Measuring the length of saphenous vein grafts at the time of coronary artery bypass grafting can be problematic, especially when proximal anastomoses are performed with the cross-clamp still in place. The heart is decompressed on cardiopulmonary bypass and much smaller than when beating. When cardiac volume increases at the termination of cardiopulmonary bypass [2], or when cardiac failure and distention occur [1], a previously acceptable graft length may become insufficient. Most surgeons, therefore, tend to err on the side of long vein grafts. If such conduits kink because of too long a length, or are overstretched because of too short a length, a vicious cycle of ischemia and distention can occur, and the graft may have acute thrombosis [1,3].
Various techniques have been tried for dealing with aortocoronary graft lengths and with kinks and twists in the grafts [4]. The most commonly used ones are (1) measuring lengths with a stretch of stout black silk suture before the institution of bypass, (2) partially occluding the venous line after the distal anastomoses have been performed and measuring the vein grafts up to the chosen points on the aorta, (3) doing the top ends off bypass (possible in the majority of patients) [5], and (4) tacking down a long graft to either the pulmonary artery or the right ventricle to make it lie in a smooth curve. Some of these methods either are not very easily done or are not accurate, and the problem of length adjustment for aortocoronary saphenous vein bypass grafts remains.
The method described here by us can add to the surgeon’s armamentarium and can prove to be a useful tool whenever a saphenous vein bypass graft is too long.
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References
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- Spray T.L., Roberts W.C. Tension on coronary bypass conduits. J Thorac Cardiovasc Surg 1976;72:282-287.[Abstract]
- Eguaras M.G., Garcia M.A., Granados J., Conchea M. Accurate length adjustment of right or circumflex coronary artery bypass grafting. J Cardiovasc Surg 1986;27:681-682.[Medline]
- Urschel H.C., Razzuk M.A., Wood R.E., Paulson D.L. Factors influencing patency of aortocoronary artery saphenous vein grafts. Surgery 1972;72:1048-1063.[Medline]
- Mills N.L., Swayze Rigby C. Techniques of coronary artery operations and reoperations. In: Baue A.E., Geha A.S., Hammond G.L., Lak H., Naunheim K.S., eds. . Glenn’s thoracic and cardiovascular surgery. Norwalk, CT: Appleton & Lange, 1991:1771-1789.
- Flemma R.J., Singh H.M., Tector A.J. A method for revascularization of circumflex marginal coronary arteries. Ann Thorac Surg 1975;20:706-708.[Abstract]
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Abstract
Introduction
