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Ann Thorac Surg 1999;67:1536-1537
© 1999 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Hospital, Bursa, Turkey
To the Editor
We very much enjoyed the recent article by Dr Durrani and colleagues [1]. No matter how strictly the precautions are adhered to, every surgeon occasionally faces problems with the adjustment of saphenous vein graft length in aortocoronary bypass procedures. Whether they are too long or short, the kinky or strained grafts are known to cause serious consequences postoperatively [1, 2]. For this reason, some doctors have developed their own ways of dealing with such mishaps. We should admit that those proposed by Dr Durrani and associates are excellent ones; reminding us there is always room for simple solutions. We would like to contribute two additional methods that could be used in suitable cases; one for lengthy grafts and one for short right-sided grafts.
Tacking down the long grafts to the great arteries, ventricles or atria to make them lie in smooth curves is a widely used method to prevent kinking. In addition to those structures, we have found the pericardial cradle to be a more convenient attachment site especially for the right-sided grafts. To provide a fine curvilinear or meandering course, we use a number of tiny sutures both on the pericardium and graft, or just on the pericardium and around the graft if sufficient. Then, we tie them loosely to ease the take-down if improperly placed. The technique is somewhat cumbersome on the left, but feasible if the lateral regions of the pericardium are used. Another disadvantage is that once the graft is fixed in position, inferoposterior aspects of the heart are unreachable in bleeding control unless you untack these stitches. Fortunately, this has not often been necessary in our practice, and as on the right, it has usually been possible to overcome the kinky left-sided grafts.
The situation is more bothersome in cases of tight grafts. Adding an additional segment to the graft, reanastomosing it to a more suitable site on the aorta or a nearby vein graft, or rerouting it through an alternative path are the generally adopted techniques to alleviate the stretch in short grafts. In 2 patients in whom the right coronary bypass conduits were under strain because of bulky and distended right atria, we were able to relieve the tension with atrial purse-string sutures. Namely, we created grooves made up of atrial dimples in series beneath the course of the strained vein grafts by taking particular care to stay away from the sinus node. One of the patients had ischemic signs. These disappeared immediately. We did not see any rhythm disturbances, bleeding, or other complications in either of them.
We are well aware that these methods are not devoid of inherent problems, and they are not the most ideal solutions applicable in every patient. Although they are open to criticism in many respects, they are simple, useful techniques that save ischemic time, and prevent aortic reclamping and reanastomosing, which could be of crucial importance for some patients. The feasibility has to be judged individually, the expected benefits should outweigh the potential risks, and the final result must be highly satisfactory. If these conditions are reasonably met, the methods described herein and those of Dr Durrani and colleagues are worth trying, and can be quite effective. Otherwise, it is wiser to consider a more straightforward approach; redoing the proximal anastomosis in precise length once again.
References
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