Ann Thorac Surg 2000;70:681-682
© 2000 The Society of Thoracic Surgeons
How to do it
External shunt for off-pump coronary artery bypass grafting: distal coronary perfusion catheter
Hirokuni Arai, MDa,
Tetsuya Yoshida, MDa,
Hiroyuki Izumi, MDa,
Makoto Sunamori, MDa
a Department of Cardiovascular Surgery, Hokushin General Hospital, Nagano, Japan
Address reprint requests to Dr Arai, Department of Cardiothoracic Surgery, School of Medicine, Tokyo Medical and Dental University, 1–5-45, Yushima, Bunkyo-ku, Tokyo, 113–8519, Japan
e-mail: hiro.tsrg{at}tmd.ac.jp
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Abstract
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We invented a simple external shunt catheter for off-pump coronary artery bypass grafting. This catheter maintains coronary perfusion from femoral artery, prevents ischemia, reduces back-bleeding, and acts as a suture guide by preventing accidental missuturing of the posterior coronary wall. The insertion and withdraw technique is easier than intraluminal shunt. This catheter would be a useful tool for myocardial protection during off-pump revascularization.
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Introduction
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As the feasibility of off-pump coronary artery bypass grafting procedures has been well demonstrated, it is becoming increasingly popular worldwide [1]. The technique offers many advantages to the patient in terms of potential for lower morbidity and mortality. However, temporary occlusion of the coronary artery, which is often required to perform the anastomosis, brings forth potential hemodynamic compromise.
In this report, we describe a simple external shunt catheter, which maintains coronary perfusion to prevent myocardial ischemia during off-pump revascularization.
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Technique
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The coronary perfusion catheter (Sumitomo Bakelite, Inc, Tokyo, Japan) is made of polyurethane. Its length is 80 cm and outer diameter is 2.5 mm (Fig 1A). The distal end of the perfusion catheter is tapered to be 1.0 mm (normal type) or 1.6 mm (large type) of outer diameter. The shape of the distal end is designed as either straight or right angle (Fig 1B). A small silicone tip is attached to the distal end of the catheter. The outer diameter of the tip is either 1.4 or 1.7 mm for normal type, and 2.0 mm for large one. The proximal end of the catheter is designed as a male connector.
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Fig 1. (A) The coronary perfusion catheter is a simple external shunt. (B) The distal end is designed as either right angle (a) or straight (b).
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Patients are fully heparinized (activated clotting time, > 400 seconds) and a 6F arterial sheath (MEDIKIT Inc, Tokyo, Japan) is inserted into the femoral artery. The proximal end of the catheter is connected to the three-way stopcock of the sidearm of the arterial sheath. With the three-way stopcock open, the catheter is de-aired and free flow is confirmed. Elastic polyurethane sutures (Matuda-ika Inc, Tokyo, Japan) encircle the coronary artery to snare the upstream and downstream from the arteriotomy site. After arteriotomy, the distal end of the catheter is introduced into the distal coronary artery with the blood flowing. The proximal snare is tightened and the distal snare is lightly applied over the catheter. The distal coronary artery is perfused through the catheter, depending on the blood pressure of the femoral artery into which the arterial sheath is placed. This prevents myocardial ischemia during anastomosis. In addition, the catheter supports the coronary edge, making it impossible to catch the posterior wall in the toe suture. Suturing the arterial graft to the coronary artery is performed with running suture of 7-0 or 8-0 monofilament sutures with the catheter in place (Fig 2). Before the suture is secured, the catheter is removed.
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Fig 2. The coronary perfusion catheter maintains coronary perfusion from the femoral artery. The catheter is directly inserted into the left anterior descending coronary artery. Arrowsindicate the coronary perfusion catheter.
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The 1.7-mm coronary perfusion catheter was used in 6 patients (seven grafts) undergoing of off-pump coronary artery bypass grafting procedures, in which either the left anterior descending or the proximal right coronary artery was anastomosed. Intraoperative catheter flow measurements were performed during anastomosis, using ultrasonic flow meter (Transonic Systems Inc, Ithaca, NY). Mean perfusion time and mean flow rate were 18 ± 5 minutes and 13 ± 4 mL/min, respectively. In 1 patient, the electrocardiogram showed that the ST segment increased when the left anterior descending coronary artery was test clamped, which resolved quickly after placement of the catheter. In another patient, the test-clamp of left anterior descending coronary artery induced hypotension and bradycardia, which resolved with the use of the catheter. There was no hospital death and no perioperative myocardial infarction. Postoperative coronary angiography, which was performed in 4 patients, showed that all the grafts were patent and no stenosis was observed in distal coronary arteries where coronary perfusion catheters were placed.
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Comment
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For the purpose of preventing ischemia in off-pump revascularization, a shunt has been reported to be effective [1–3]. However, previously reported external shunt circuits were complex and not easy to handle because they were a combination of an intravenous or an arterial catheter with extension tubing and connection apparatus, which were not originally designed for this purpose [4, 5].
Recently, various intraluminal shunts became commercially available. These intraluminal shunts require insertion of both ends through limited arteriotomy, which is sometimes troublesome. There exists concern about possible endothelial injury related to inadvertent insertion. Moreover, the threaded tab attached to the intraluminal shunt sometimes gets entangled in the suture.
The coronary perfusion catheter presented here is a simple external shunt that effectively prevents myocardial ischemia. Without any extension tubing, the catheter is prepared for use with a simple connection to the sidearm of the femoral arterial sheath. The reason why the femoral artery is used for the inflow of blood instead of the aorta is to avoid possible cerebral embolism related to arterial sheath insertion into the aorta. The insertion and withdrawal technique is extremely simple and would be less traumatic than an intraluminal shunt. Furthermore, we believe that in the near future this catheter would be applicable for endoscopic coronary artery bypass grafting.
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Acknowledgments
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We acknowledge the technical contributions of Haruhiko Masuda.
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References
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Baumgartner F.J., Gheissari A., Capouya E.R., Panagiotides G.P., Katouzian A., Yokoyama T. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999;67:1653-1658.[Abstract/Free Full Text]
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Rivetti L.A., Gandra S.M.A. Initial experience using an intraluminal shunt during revascularization of the beating heart. Ann Thorac Surg 1997;63:1742-1747.[Abstract/Free Full Text]
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Lucchetti V., Capasso F., Caputo M., et al. Intracoronary shunt prevents left ventricular function impairment during beating heart coronary revascularization. Eur J Cardiothorac Surg 1999;15:255-259.[Abstract/Free Full Text]
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Borges M.F., Spohn P.K., Coulson A.S. Arrhythmia/ischemia management during minimally invasive cardiac operation. Ann Thorac Surg 1997;64:843-844.[Abstract/Free Full Text]
Accepted for publication March 25, 2000.
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Abstract
Introduction
