| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2003;75:1626-1629
© 2003 The Society of Thoracic Surgeons
a Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Accepted for publication October 15, 2002.
* Address reprint requests to Dr Reuthebuch, Clinic for Cardiovascular Surgery, University Hospital Zurich, Raemistrasse 100, CH 8091 Zurich, Switzerland
e-mail: oliver.reuthebuch{at}chi.usz.ch
 |
Abstract |
|---|
 Top Abstract IntroductionCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
Recently the Symmetry Bypass System (SJM) became available and it is successfully being used for vein-graft to aorta anastomoses in OPCAB operations [3]. In our institution this device is now frequently applied in OPCAB procedures.
We report a complication associated with the use of the Symmetry Bypass System (SJM) in a patient undergoing a standard OPCAB procedure.
A 70-year-old man was admitted to our institution with Canadian Cardiovascular Society class IV angina for elective coronary artery bypass operation. The patient had a history of hypertension, hypercholesterolemia, and peripheral vascular disease. Coronary artery angiography revealed a 70% stenosis of the left main coronary artery, a 75% stenosis of the left anterior descending coronary artery, and a totally occluded right coronary artery. The left ventricular ejection fraction was measured at 65%. The routinely performed transesophageal echocardiography demonstrated multiple protruding atheromatous plaques of grade IV-V [4]. Consequently, it was decided to proceed with an OPCAB operation. To reduce the number of proximal anastomoses bilateral internal mammary arteries were dissected. For proximal vein graft anastomoses, the sutureless Symmetry Bypass System (SJM) was considered.
After median sternotomy the left and right internal mammary arteries were skeletonized for optimal length. After placement of deep pericardial exposure sutures, the beating heart was stabilized with the Medtronic Octopus retractor (Medtronic, DLP, Grand Rapids, MI). Hand-sewn anastomoses were performed to the right coronary artery by using the right internal mammary artery and to the left anterior descending coronary artery by using the left internal mammary artery. The vein graft was prepared, fitted into the sutureless connector system, and proximal anastomosis was performed. Sequentially, anastomoses to the first diagonal branch and the circumflex coronary artery were completed. Intraoperative assessment of graft blood flow demonstrated a severely reduced flow in the vein graft between the aorta and first diagonal branch (Fig 1A). In order to accurately localize the underlying problem, 0.5 mL indocyanine green were given intravenously, and distribution of the dye was visualized by the SPY intraoperative imaging system (Novadaq). An occlusion of the proximal mechanical anastomosis of the vein graft was found, whereas good flow could be detected in the vein graft between the diagonal branch and the circumflex coronary artery (Fig 1B, 1C). Therefore the Symmetry Bypass System (SJM) had to be removed, and the proximal anastomosis had to be corrected. Because of the remaining aortic hole, this had to be done in a standard fashion using a side-biting clamp. Direct visual inspection of the proximal anastomosis revealed an occlusion by a mobile aortic atheroma that obviously was not cut by the Symmetry Bypass System aortic cutter (SJM), but was only pushed aside. After the graft was cleared of debris using backflow through a diagonal branch, the vein graft was reimplanted hand-sewn in. Flow measurement was performed (Fig 2A) and indocyanine green visualization (Fig 2B, 2C) demonstrated a good blood flow through the bypass graft. The postoperative course was uneventful and the patient was discharged on postoperative day 8. Postoperative electrocardiogram did not show any ischemic alterations nor any elevated heart enzymes (creatine kinase [CK] 65 U/L, heart specific creatine kinase [CK–MB] 17 U/L, Troponine T 0, 18).
|
|
|
Comment |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
Eckstein and colleagues [3] evaluated 20 consecutive patients receiving at least one mechanical proximal anastomosis with the symmetry aortic connector system. They describe one case of device failure as leaking of the anastomoses, which was attributed to improper handling of the aortic cutter. The insertion of the aortic cutter at an angle other than 90 degrees led to the creation of an intimal flap. This flap was not visible during insertion of the loaded device, but during delivery it was found to be between the aortic wall and the mechanical device resulting in minor bleeding. This complication was also observed in our initial cases, and accurate loading of the vein graft and proper application of the aortic cutter appears crucial for successful performance.
Surprisingly, in our patient we found a mobile atheroma plaque to occlude the proximal mechanical anastomosis after completion. It appears that correct application of the mechanical anastomosis device could not avoid this complication. Intraoperative assessment of graft blood flow is routinely performed with a flowmeter (Medi-Stim, Oslo, Norway) in our institution, and in our patient an impaired function of the vein graft was detected. The following application of the indocyanine green and SPY intraoperative imaging system (Novadaq) allowed an immediate and more precise diagnosis of the underlying problem.
The SPY imaging system (Novadaq) is a novel technology allowing visualization of the coronary vasculature, assessment of coronary artery bypass graft patency, and documentation of correct graft placement. The imaging technology is based on the fluorescence properties of indocyanine green, which rapidly binds to plasma proteins and therefore is confined to the vascular space. When illuminated at 806 nm by a laser diode, indocyanine green fluoresces emitting light of 320 nm. This fluorescence signal is captured using a computer controlled display (CCD) video camera and videotaped. We found this novel technology very accurate and helpful to assess graft dysfunction.
In summary we present a patient undergoing OPCAB operation complicated by an occlusion of the proximal vein graft anastomosis by a mobile atheroma plaque after application of the Symmetry Bypass System (SJM).
Therefore we strongly recommend the control of graft patency after bypass operation, especially in cases using new devices, regardless of which system is used.
|
References |
|---|
|
TopAbstractIntroductionCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  T. Shimokawa, S. Manabe, T. Sawada, S. Matsuyama, T. Fukui, and S. Takanashi Intermediate-term patency of saphenous vein graft with a clampless hand-sewn proximal anastomosis device after off-pump coronary bypass grafting. Ann. Thorac. Surg., May 1, 2009; 87(5): 1416 - 1420. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Kai, M. Hanyu, Y. Soga, T. Nomoto, J. Nakano, T. Matsuo, M. Kawato, and H. Okabayashi Midterm patency rate after saphenous vein grafting with a PAS-Port device. J. Thorac. Cardiovasc. Surg., February 1, 2009; 137(2): 503 - 504. [Full Text] [PDF]
|
|
|
|
|
|
J. F. Gummert, S. Demertzis, K. Matschke, U. Kappert, M. Anssar, F. Siclari, V. Falk, E. L. Alderman, and W. Harringer Six-Month Angiographic Follow-Up of the PAS-Port II Clinical Trial Ann. Thorac. Surg., January 1, 2006; 81(1): 90 - 96. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Matschke, U. Kappert, and J. Schneider Graft Occlusion After Deployment of the Aortic Connector Symmetry System: Is Anticoagulation a Necessity? Ann. Thorac. Surg., November 1, 2004; 78(5): 1878 - 1878. [Full Text] [PDF]
|
|
|
|
|
|
O. Reuthebuch, A. Kadner, and M. I. Turina Reply Ann. Thorac. Surg., November 1, 2004; 78(5): 1878 - 1879. [Full Text] [PDF]
|
|
|
|
 |
|
 J. J. Cavendish, W. F. Penny, M. M. Madani, S. Keramati, O. Ben-Yehuda, D. G. Blanchard, E. Mahmud, A. Perricone, and S. Tsimikas Severe ostial saphenous vein graft disease leading to acute coronary syndromes following proximal aorto-saphenous anastomoses with the symmetry bypass connector device: Is it a suture device or a "stent"? J. Am. Coll. Cardiol., January 7, 2004; 43(1): 133 - 139. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
