Ann Thorac Surg 2002;73:1663-1664
© 2002 The Society of Thoracic Surgeons
How to do it
Everting mattress running suture: an improved technique of atrial anastomosis in human lung transplantation
Marc de Perrot, MD, MSa,
Shaf Keshavjee, MD, MS*a
a Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
Accepted for publication November 15, 2001.
* Address reprint requests to Dr Keshavjee, Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St, EN 10-224, Toronto, Ontario M5G 2C4, Canada
e-mail: shaf.keshavjee{at}uhn.on.ca
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Abstract
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Significant complications related to the venous anastomosis have been reported in clinical lung transplantation, and it has been suggested that the incidence of pulmonary vein complications may have been previously underestimated. In our institution, we have adopted the horizontal everting mattress running suture as standard practice for the venous anastomosis in human lung transplantation. This technique is easier to perform than the regular over-and-over sutures, and allows suturing of the donor and recipient atrial cuffs in a straight line, opposing endothelium to endothelium, thus limiting the presence of redundant and potentially thrombogenic tissue in the lumen. This technique should help reduce the risk of venous anastomotic complications.
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Introduction
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Lung transplantation is a widely accepted therapy for end-stage lung diseases. The incidence of severe complications in the early postoperative period ranges between 15% and 30% [1]. Severe complications related to the venous anastomosis have been reported to occur in 1% to 2% of cases and to result in pulmonary venous congestion or cerebrovascular emboli [2–4]. Recent data, however, suggest that the incidence of pulmonary vein complications may have been previously underestimated. Indeed, abnormalities in the vicinity of the pulmonary venous anastomosis have been observed in 23% to 29% of the patients undergoing lung transplantation in some centers where the pulmonary venous anastomoses were systematically screened by transesophageal echocardiography [5, 6].
The original technique of venous anastomosis for lung transplantation consists of anastomosing a cuff of atrium from the donor to the recipient with an over-and-over running suture [7]. The atrial anastomosis, described initially in 1950, presents advantages over direct pulmonary vein anastomoses in that it allows for suturing of a larger surface of tougher tissue, and it limits the number of anastomoses to one [8]. An everting mattress suture has long been used experimentally for the venous anastomosis in large animals to reduce the risk of thrombosis. The technique has also been reported clinically to anastomose the two pulmonary veins separately during a right single lung transplant [9]. In our institution, we have adopted the horizontal everting mattress running suture as our standard technique of atrial anastomosis in human lung transplantation since 1995.
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Technique
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After the bronchial and arterial anastomoses have been completed, the venous anastomosis is performed. Lateral traction on the previously divided pulmonary vein stumps enables placement of the atrial clamp. As usual, the pulmonary vein stumps are then amputated and the bridge of tissue between the two stumps is divided to create a single cuff for the anastomosis. A double-ended 4-0 polypropylene suture (90-cm long) is placed at the superior atrial margin and a second similar suture is placed at the inferior margin. The anastomosis is then performed using a horizontal everting mattress running suture (Fig 1).
It is optimal to start at the superior end of the atrium on the left side and at the inferior end on the right side. Gentle traction on the other suture (that is not being used) facilitates lining up the tissues. The donor and recipient atrial cuffs are sewn in a straight line and are left distant from each other until the back wall stitches are all placed. The two ends of the first suture are then pulled snugly to bring the anastomosis together. The second (holding) suture is then tied and the first suture is tied to it. The anterior wall is sewn halfway with the second suture, using an everting mattress suture technique again. The remaining end of the first suture, which was initially left untied, is used for the other half of the anterior wall (Fig 2). Following completion of the anastomosis, the lung is gently reinflated and gradually reperfused by slowly releasing the pulmonary artery clamp. Once the lung is de-aired through the open atrial anastomosis, the atrial clamp is removed and then the two sutures are tied together, leaving the suture line interrupted in two places. It is important to pull the suture snugly before tying to securely oppose the tissues.
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Fig 1. Two double-ended 4-0 polypropylene sutures (90-cm long each) are respectively placed at the superior and inferior atrial margins and left untied. The anastomosis is performed using a horizontal everting mattress running suture, starting at the inferior end on the right side and at the superior end of the atrium on the left side.
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Fig 2. After the back wall is completed, the second (holding) suture is tied and the first suture (which was used for the back wall) is tied to it. The anterior wall is sewn halfway with the second suture, the other half being completed with a continuation of the first suture, using an everting mattress suture technique again.
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Comment
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We have found this suture technique to be easier to perform than the regular over-and-over running anastomosis, because the donor atrium can be sewn apart from the recipient atrium and brought together after completion of the posterior wall of the anastomosis. In addition, this technique allows sewing of the donor and recipient atrial cuffs in a straight line with guaranteed endothelium-to-endothelium apposition. This technique decreases the likelihood of having potentially thrombogenic redundant tissue within the lumen of the left atrium.
We have performed over 200 lung transplants (almost 400 venous anastomoses) using this technique and we have not experienced any complications related to the venous anastomosis itself. Although we do not routinely perform transesophageal echocardiography on all lung transplant recipients, transesophageal echocardiography is performed if there is any concern at all; no venous anastomotic complications have ever been documented in any of the studies done. We feel that this modified technique of atrial anastomosis for lung transplantation in humans represents an improvement over the originally described technique in that it is technically easier to perform and it allows suturing of the donor and recipient atrial cuffs in a straight line, opposing endothelium to endothelium, thus limiting the presence of redundant and potentially thrombogenic tissue in the lumen. This technique should help reduce the risk of venous anastomotic complications.
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References
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Hosenpud J.D., Benett L.E., Keck B.M., Boucek M.M., Novick R.J. The registry of the International Society for Heart and Lung Transplantation: Seventeenth official report—2000. J Heart Lung Transplant 2000;19:909-931.[Medline]
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Sarsam M.A.I., Yonan N.A., Beton D., McMaster D., Deiraniya A.K. Early pulmonary vein thrombosis after single lung transplantation. J Heart Lung Transplant 1993;12:17-19.[Medline]
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Michel-Cherqui M., Brusset A., Liu N., et al. Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. A report on 18 cases. Chest 1997;111:1229-1235.
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Leibowitz D.W., Smith C.R., Michler R.E., et al. Incidence of pulmonary vein complications after lung transplantation: a prospective transesophageal echocardiographic study. J Am Coll Cardiol 1994;24:671-675.[Abstract]
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Cooper J.D., Pearson F.G., Patterson G.A., et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173-181.[Abstract]
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Metras H. Note preliminaire sur la greffe totale du poumon chez le chien. C R Acad Sci [III] 1950;231:1176-1177.
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LoCicero J., Shih S.R., Zhao F., Frederiksen J.W., Hartz R.S., Michaelis L.L. Pulmonary venous anastomosis in lung transplantation without donor left atrium. J Thorac Cardiovasc Surg 1989;97:582-586.[Abstract]
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Twenty-year experience of lung transplantation at a single center: Influence of recipient diagnosis on long-term survival
J. Thorac. Cardiovasc. Surg.,
May 1, 2004;
127(5):
1493 - 1501.
[Abstract]
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Abstract
Introduction
