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Ann Thorac Surg 2002;73:1000-1001
© 2002 The Society of Thoracic Surgeons

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How to do it

Avoiding aortic clamping during coronary artery bypass using an automated anastomotic device

^a Division of Cardiothoracic Surgery, McGill University Health Center, Montreal, Quebec, Canada

Accepted for publication October 24, 2001.

* Address reprint requests to Dr Shennib, Division of Cardiothoracic Surgery, McGill University Health Center, 1650 Cedar Ave, Room L9-122, Montreal, Quebec H3G 1A4, Canada
e-mail: hani.shennib{at}muhc.mcgill.ca

	Abstract

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In its current application, off-pump coronary artery bypass grafting (OPCAB) requires clamping of the aorta to perform the proximal anastomosis. One of the important theoretical advantages of OPCAB is to avoid the undesirable effects of cross-clamping of the aorta. We report our early experience with a technique of no aortic clamping using the St. Jude aortic connector system in 11 patients.

	Introduction

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One of the important theoretical advantages of off-pump coronary artery bypass grafting (OPCAB) is to avoid the undesirable effects of cross-clamping of the aorta. Numerous investigators have designed and used many anastomotic devices for coronary artery bypass grafting (CABG) up to the present [1–4]. Unfortunately, some devices had limitations which rendered their clinical use unsatisfactory. We report the use of a new anastomotic device, the aortic connector system (ACS; St. Jude Medical, Inc, St. Paul, MN), and this report designates the operative techniques and surgical considerations during the deployment of this device.

	Technique

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From March to June 2001, 11 patients underwent CABG using the ACS proximal anastomotic device. Of these patients, 9 underwent OPCAB with no aortic clamping. The patients were aged 60.1 ± 10.1 years (all male), and 6 of them were diagnosed with unstable angina. All patients underwent CABG through a median sternotomy with or without cardiopulmonary bypass using the usual technique to which the following procedures were added.

The saphenous vein was harvested through small incisions, and inspected to determine its adequacy for the device. Initially, we tied all the tributaries to the vein in order not to interfere with the device deployment mechanism. Subsequently, the branches were clipped after completing the proximal anastomosis. The saphenous vein graft was inserted into the release tubes through the transfer sheath and attached to the aortic connector. The aortic connector was set into the handle, and the delivery system was prepared to produce the anastomosis. The aortic cutter was used to make a hole without clamping the aortic wall, and bleeding from the hole was controlled with a finger. Then the delivery system was inserted into the anastomosis site, and the button was pushed for releasing the struts. This step deployed the internal struts of the aortic connector on the inside of the aorta, and the external struts on the outside. In all cases, the proximal anastomoses were performed before the distal anastomoses.

Whenever more than two or three proximal anastomoses to the aorta were required, we sequenced the proximal end of the additional graft to the side of another graft. Spacing of proximal anastomosis on the aorta is a key consideration, as failure of deployment adjacent to an existing aortic anastomosis may hinder application of a side-biting aortic clamp that may be needed in case of an emergency (Fig 1). Furthermore, we choose to implant the proximal anastomosis on the side, rather than on the top of the aorta, in order to avoid angulations. Finally, it is important to leave an extra length of vein graft to avoid tension once the distal anastomosis is completed.

View larger version (132K): [in this window] [in a new window]   Fig 1. Operative view of the completed surgical procedure showing the proximal anastomosis after using the aortic connector system (arrows), and the sequential vein anastomosis to diagonal and posterior descending artery.

	Results

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View larger version (149K): [in this window] [in a new window]   Fig 2. Postoperative angiographic view of the completed surgical procedure showing the deployed struts (arrow) and widely patent proximal anastomosis. One graft is to the second obtuse marginal, and a second graft is sequential to the first diagonal branch.

	Comment

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Introduction of new technology, however, may have important impact on the conduct of the operative procedure. For example, this anastomotic device requires performance of the proximal anastomosis first. Second, even though the proximal anastomotic device rarely leaks, it is important to leave adequate space between anastomotic sites to apply a side-biting clamp if needed. Third, because of the current cost of the device and in the presence of a small aorta, one may consider using a lesser number of aortic anastomoses and revert to sequential technique to add on vein grafts. Fourth, as in most cases where proximal anastomosis is used first, it is pertinent to leave vein grafts longer than usual to avoid tension on the anastomosis and to avoid the risk of kinking due to short grafts. Finally, and most importantly, the aorta must be evaluated carefully so that the anastomosis is placed in an area with the least potential for injury or embolization. We currently use digital palpitation and periaortic Doppler to rule out atheromatous disease in patients at high risk.

We conclude that the St. Jude anastomotic device produces a simple, effective way of performing the proximal aortic anastomosis without the need for clamping the aorta; technical considerations are discussed. We await results from other studies to confirm that such an approach may decrease the incidence of embolic showering.

	Acknowledgments

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The authors acknowledge receipt of a research grant from St. Jude Medical, Inc, in partial support of this study.

	References

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1. Heijmen R.H., Hinchliffe P., Borst C., et al. A novel one-shot anastomotic stapler prototype for coronary bypass grafting on the beating heart: feasibility in the pig. J Thorac Cardiovasc Surg 1999;117:117-125.[Abstract/Free Full Text]
2. Nataf P., Hinchcliffe P., Manzo S., et al. Facilitated vascular anastomoses: the one-shot device. Ann Thorac Surg 1998;66:1041-1044.[Abstract/Free Full Text]
3. Werker P.M.N., Kon M. Review of facilitated approach to vascular anastomosis surgery. Ann Thorac Surg 1997;63:S122-S127.
4. Calafiore A.M., Bar-El Y., Vitolla G., et al. Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta. J Thorac Cardiovasc Surg 2001;121:854-858.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jean F. Morin Hani Shennib Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Endo, M. Articles by Shennib, H. Search for Related Content PubMed PubMed Citation Articles by Endo, M. Articles by Shennib, H.