Ann Thorac Surg 2003;76:633-634
© 2003 The Society of Thoracic Surgeons
How to do it
Technique of using the St. Jude aortic connector with the radial artery
Kit V. Arom, MD, PhDa*,
Vibul Jotisakulratana, MDa,
Vitoon Pitiguagool, MDa,
Sujit Banyatpiyaphod, MDa,
Piyapan Pamornsing, MDa
a Bangkok Heart Institute, Bangkok, Thailand
Accepted for publication January 7, 2003.
* Address reprint requests to Dr Arom, Bangkok Heart Institute, Bangkok Hospital, 2 Soi Soonvijai 7, Bangkok, Thailand 10320, USA.
e-mail: karom{at}csa-heart.com
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Abstract
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We present a technique for the use of St. Jude Aortic Connector System with the radial artery. This technique will allow surgeons, who prefer the radial artery to the vein, to use this approach whenever feasible.
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Introduction
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A step advancing the process of myocardial revascularization has been the recent introduction of devices to mechanically construct proximal and distal vascular anastomoses. The main goals to be achieved with the proximal device are reduction of the manipulation of the ascending aorta, which may be the most important factor in reducing neurologic complications. The advantages of these devices are several, and include increased consistency and speed of construction, elimination of the need for aortic clamping, and the ability to perform the proximal anastomoses first, without adding a pressure load to the ventricle by partial occlusion and with the benefit of immediate reperfusion of the grafted area on completion of distal suturing [1].
The radial artery has been used more and more recently by many surgeons as a way of reducing use of saphenous vein. It has been shown that the radial artery can maintain greater late patentcy than the saphenous vein [2].
Pedicle harvesting including the adjacent veins and surrounding connective tissue is considered to be standard for radial artery grafting. However, our group has been using the skeletonization technique for the past several years. When surrounding tissue along the length of the radial artery was incised down to the adventitia with or without removal of the satellite veins, we have observed the radial conduit to be free from spasm. This finding was recently confirmed by the work of Amano and colleagues [3].
The St. Jude Medical Anastomotic Technology group has developed a mechanical anastomotic device for vein graft-to-aorta anastomosis in coronary artery bypass grafting. To the best of our knowledge, this device has never been used with the radial artery before, mainly because the device was designed for the denuded vein and not for a conduit with a pedicle.
The skeletonized radial artery looks similar to the small saphenous vein, and the radial artery would fit in very well with the two smaller aortic connector sizes (gray 4.5 to 5.0 mm and green 5.0 to 5.5 mm). This led us to try the sutureless aortic connector for proximal radial artery graft anastomosis. To date we have used a radial conduit with the St. Jude Aortic Connector on more than 20 occasions.
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Technique
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The radial artery was immobilized in standard fashion including the satellite vein, covering fascia, and the surrounding adipose tissue using the Harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH) or electrical cautery. The branches of the radial artery were divided just distal to the satellite vein, but not clipped at this point to avoid the bulkiness of multiple clips when inserted into the release tube. The external diameter of the graft is assessed in 0.25-mm increments to match the most appropriate size of the three different connector systems that are available for vessel diameters from 4.5 to 6.5 mm. More than 90% of radial arteries we have seen were larger after the artery was skeletonized and the longitudinal incision made down to the adventitia.
After the artery was soaked with papaverine hydrochloride or milrinone lactate for a few minutes, the artery relaxed and accepted the vessel transfer sheath nicely. Particular care must be given at this point to be sure that the vessel transfer sheath passes through the artery with ease. If any resistance was noticed during the attempt to insert the vessel transfer sheath, the radial artery was not used with this connector system, because any damage to the intima could lead to early intimal hyperplasia as seen with the venous conduit.
The radial artery was pulled over the vessel transfer sheath and then guided over the release system. It was then brought over the hooks of the connector with a fine-tip forceps. Then, like the vein, the artery was gently pierced through the connector hooks, and the release tube was placed into the handle. Advancing the radial artery inside of the release tube was accomplished gently while the remaining fatty tissue and satellite vein were trimmed enough for the radial artery to pass through the release tube without resistance (Fig 1)
. Having the rigid vessel transfer sheath inside the artery made trimming much easier. Particular attention was needed again at this point, because tightness in the release tube will cause difficulty during retraction of the handle and cause tension on the connector. Holding on to the proximal part of the artery near the connector while pulling will release the tension at the anastomotic site and facilitate removing all components from the artery. At this point, time was spent clipping all of the side branches individually until good hemostasis was obtained (usually 5 to 15 branches need to be clipped). Otherwise, care of the radial artery was no different from our routine skeletonization of the artery
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Fig 1. Operative photo shows advancement of the radial artery inside of the release tube. This was accomplished gently while the remaining fatty tissue was being trimmed. The rigid vessel transfer sheath is inside of the artery, making the trimming much easier. Tightness in the release tube may cause difficulty pulling back the handle and cause tension on the connector.
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The radial artery was then passed underneath the left internal mammary artery under direct vision to maintain good alignment and a perfect length for the first side-to-side anastomosis either to the intermediate artery or the first oblique marginal artery (Fig 2)
. The length of the artery between the aortic connector and the first distal anastomosis was verified to be sure that the graft lay nicely above the pulmonary artery and came off the aorta at a perfect 90-degree angle. Sequential anastomosis to the other branches was performed in the routine fashion.
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Fig 2. Operative view from the surgeon’s site depicting a radial artery secured to the aorta with the Aortic Connecting Device. Note the two skeletonized radial arteries and small clips. The radial conduit has a 4.5-mm outer diameter and is free from spasm.
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Comment
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More than 20,000 of the St. Jude proximal Aortic Connector Systems (St. Jude Medical, Inc, St. Paul, MN) have been used with the venous conduit since it was released in May 2001. There have been minimal problems, which most commonly have been associated with the learning curve for loading the vein on the device and positioning of the vein on the aorta [4]. This device, however, has been approved by the U.S. Food and Drug Administration to be used only with the venous conduit.
Avoiding cross-clamping of the aorta routinely may offer the patient less chance of developing postoperative neurologic deficit. We have tried this aortic connector system with the radial artery, and subsequently use of the radial artery and all arterial grafts has become routine in our daily practice. Our arterial grafts include using the left internal mammary artery to the left anterior descending coronary artery and diagonal arteries (two to three distal anastomoses); the radial artery (usually left radial artery with one proximal anastomosis to intermediate and branches of circumflex system); and, when the radial artery is long enough, using it to anastomose with the posterolateral branch of the right system as well. The distal right coronary artery or its branches are anastomosed with the gastroepiploic artery. The free flow of the radial conduit before the distal anastomosis was 345 ± 125 mL/min.
All arterial off-pump coronary artery bypass graft surgery is being used routinely at our institution. Adding a no-clamp proximal aortic anastomosis with the available aortic connector system could minimize postoperative neurologic deficit. The St. Jude Aortic Connector System can be used safely with a skeletonized radial artery.
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References
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- Eckstein F.S., Meyer B., Bonilla L., et al. Minimizing aortic manipulation during OPCAB using the Symmetry Aortic Connector System for proximal vein graft anastomoses. Ann Thorac Surg 2001;72(Suppl):S995-S998.[Abstract/Free Full Text]
- Tatoulis J., Royse A.G., Buxton B.F., et al. The radial artery in coronary surgery: a 5-year experience—clinical and angiographic results. Ann Thorac Surg 2002;73:143-148.[Abstract/Free Full Text]
- Amano A., Takahashi A., Hirose H. Skeletonized radial artery grafting: improved angiographic results. Ann Thorac Surg 2002;73:1880-1887.[Abstract/Free Full Text]
- Mack MJ, Emery RW, Ley LR, et al. Initial experience with one hundred thirty-nine consecutive proximal anastomoses performed with a mechanical connector. Ann Thorac Surg (in press)
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Abstract
Introduction
