Ann Thorac Surg 1999;68:585-586
© 1999 The Society of Thoracic Surgeons
How To Do It
Vascular clamp for hemostasis and stabilization during minimally invasive direct coronary artery bypass
Kazutomo Goh, MDa,
Masashi Inaba, MDa,
Hiroshi Yamamoto, MDa,
Nobuyuki Akasaka, MDa,
Tadahiro Sasajima, MDa
a First Department of Surgery, Asahikawa Medical College, Asahikawa, Japan
Address reprint requests to Dr Goh, First Dept of Surgery, Asahikawa Medical College, Nishikagura 4-5-3-11, Asahikawa 078-8510, Japan
e-mail: kgoh{at}asahikawa-med.ac.jp
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Abstract
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A soft vascular clamp was used for hemostasis and stabilization of the operative field during minimally invasive direct coronary artery bypass (MIDCAB). The instrument was gently applied so that it clamps the coronary artery by grasping the adjacent myocardium. The method offered dry and stable operative field without a special instrument or technique. The surgical results have been satisfactory. We found application of the vascular clamp to be very helpful for MIDCAB.
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Introduction
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Minimally invasive direct coronary arterial bypass (MIDCAB) is now widely accepted in practice with excellent results. As the current vascular anastomosis during MIDCAB is still performed with conventional suture technique on the beating heart, hemostasis and stabilization are important for successful operation. Although many new instruments have been introduced for this purpose, we found a simple soft vascular clamp to be very effective. Our method and results are described.
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Technique
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The patient is placed in the supine position tilted slightly to the right. A small left anterolateral thoracotomy is made through the fourth or fifth intercostal space. The pericardium is opened and the left anterior descending artery (LAD) is identified and inspected. The left internal thoracic artery (ITA) is harvested either under thoracoscopy or under direct vision. Several traction sutures are placed along the pericardial margins. Two elastic traction sutures with a blunt-tipped needle are placed around the coronary artery proximal and distal to the site of anastomosis. With a gentle upward traction on the elastic sutures, a soft vascular clamp (Hendren clamp, CH 6526; Allegiance Healthcare Corporation, V. Mueller, Deerfield, IL) is applied to the myocardium adjacent to the LAD so that it can gently occlude the artery (Fig 1). It is important not to close the clamp too tight so as not to damage the epicardium and the myocardium as well as the coronary artery. Generally, adequate hemostasis can be obtained with a mild clamping force. The clamp is controlled by the assistant. The coronary artery is opened longitudinally, and the anastomosis is performed as usual. The graft flow is measured after the anastomosis. The pericardium is roughly approximated, and the closure of the chest is as in any standard thoracotomy.
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Fig 1. The vascular clamp is gently applied to the pericardium and myocardium adjacent to the targeted coronary artery. The coronary artery and its tributaries are controlled and stabilized. The vascular clamp is held by the assistant.
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Results
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We have performed MIDCAB with this technique in the last 5 patients. The left ITA was harvested and anastomosed to the LAD distal to the second diagonal branch. There has been no mortality or morbidity. The vascular clamp could be applied to the target area without difficulty or adverse incidence. No laceration on the epicardium or myocardium has been experienced. Hemostasis with this method was sufficient, and there has been no need of a carbon dioxide blower to clear the operative field. The graft flow measured intraoperatively was 41 + 11 mL/min. The peak level of MB creatine kinase was 39 ± 23 IU/L. New Q wave was not identified in the postoperative electrocardiogram. All anastomoses were patent on the angiogram taken within 1 month of operation. There was no narrowing in the native artery proximal and distal to the anastomosis (Fig 2).
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Fig 2. Coronary angiogram taken 1 month after the operation. No narrowing in the native artery was observed proximal and distal to the anastomosis.
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Comment
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Many new retractors and stabilizers have been developed to obtain optimal surgical field during MIDCAB [1–4]. With our method, no special retractor or stabilizer is necessary. In fact, we found that the usual small thoracic retractors are more easily handled than some of the newly developed retractors, and the vascular clamp held by the assistant offers excellent stabilization.
Hemostasis is usually accomplished by occluding the proximal and distal coronary artery by looping sutures, suture snares, or specially designed occluders [2, 5, 6]. The bleeding through the septal branches is cleared by saline irrigation or a carbon dioxide blower. With our vascular clamp in place, the septal branches as well as proximal and distal anterior descending artery could be controlled sufficiently. In our experience with this method, we did not need a carbon dioxide blower, and saline irrigation was infrequent.
Iatrogenic local coronary injury and subsequent stenosis caused by distal and proximal control of the coronary artery is a concern in MIDCAB [6]. With our method, the occluding force of the vascular clamp is distributed on the coronary artery via the myocardium, which may insulate the force and thus avoid the discrete occlusion force observed with suture snares. We have not experienced damage to the native artery, and we have not experienced detectable myocardial damage so far. We are expecting less damage to the coronary artery with this method. However, further long-term study is required to draw any conclusion.
It is true that the LAD may be submyocardial, and our technique may not be applied to some patients if the target vessel is deep in the myocardium. But we found that this technique can be used in many patients, if not all patients, once the artery can be identified after modest epicardial incision, because the distal portion of the artery runs fairly superficially.
Our current method of MIDCAB with a soft vascular clamp is described. We found it advantageous because it can provide excellent hemostasis and stabilization easily without any special equipment.
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References
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Shennib H., Lee A.G., Akin J. Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1997;63:988-992.[Abstract/Free Full Text]
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Boonstra P.W., Grandjean J.G., Mariani M.A. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567-569.[Abstract/Free Full Text]
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Takahashi M., Yamaguchi S., Yamamoto S. A new instrument for immobilization and hemostasis during minimally invasive direct coronary artery bypass ("MIDCAB doughnut"). J Card Surg 1997;12:185-189.[Medline]
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Subramanian V.A. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997;63:S68-S71.
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Calafiore A.M., Angelini G.D., Bergsland J., Salerno T.A. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;62:1545-1548.[Abstract/Free Full Text]
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Landreneau R.J., Mack M.J., Magovern J.A., et al. "Keyhole" coronary artery bypass surgery. Ann Surg 1996;224:453-459.[Medline]
Accepted for publication April 9, 1999.
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Abstract
Introduction
