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Ann Thorac Surg 2004;77:1550-1552
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Skeletonized radial artery graft with the St. Jude medical symmetry bypass system (aortic connector system)

Go Watanabe, MD, PhDa*, Hirofumi Takemura, MD, PhDa, Shigeyuki Tomita, MD, PhDa, Hiroshi Nagamine, MD, PhDa, Hiroyuki Kamiya, MD, PhDa, Taro Kanamori, MDa

a Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, School of Medicine, Kanazawa, Japan

Accepted for publication October 2, 2003.

* Address reprint requests to Dr Watanabe, Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine, 13-1 Takaramachi, Kanazawa 920-8641, Japan
e-mail: go{at}med.kanazawa-u.ac.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: We report our initial experience with an automatic anastomotic device using skeletonized radial artery in patients requiring off-pump coronary artery bypass grafting (CABG).

METHODS: St. Jude Medical, Inc, Symmetry Bypass System (aortic connector system [ACS]) (St Jude Medical, St. Paul, MN) was used in ten patients. Ten consecutive patients who underwent off-pump CABG and who received at least one radial artery graft proximal anastomosis using the ACS were evaluated. The radial artery (RA) was harvested in a skeletonized fashion and applied to the ACS in the same manner as applying saphenous vein graft. The creation of the anastomosis lasted no longer than a few seconds.

RESULTS: Our attempt to use the ACS for proximal anastomosis of the RA was successful in all ten patients. Mean operating time was 3.2 ± 0.6 minutes and an average of 3.0 ± 0.9 bypass grafts (range, 2 to 5 grafts) were performed. There was no postoperative fatal complication. Postoperative angiographic control showed that all grafts were widely patent including grafts other than the RA. During the mean postoperative follow-up of 10.3 ± 2.9 months, there was no cardiac-related event in any patient.

CONCLUSIONS: The St. Jude Medical Symmetry aortic connector system allows the construction of uniform and widely patent anastomoses in RA graft and does not require aortic side biting. Skeletonization of the RA is a safe and effective technique for applying ACS in off-pump CABG using multiple arterial grafts.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Minimally invasive direct coronary artery bypass grafting (CABG) is a safe alternative to the conventional CABG using cardiopulmonary bypass. However, side clamping of the ascending aorta is recognized as a possible cause for the increased incidents of preoperative cerebral vascular accident during myocardial revascularization. The growing interest in less invasive CABG techniques has generated a need to look for facilitated semiautomatic techniques to create proximal anastomoses [1, 2]. Some items are now commercially available in the United States and in European Union countries, but most of the devices are limited to saphenous vein grafts. We report here our initial experience with automatic anastomotic devices using skeletonized radial artery (RA) in ten patients requiring CABG who underwent operation on the beating heart without cardiopulmonary bypass (CPB).


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
From April 2002 through Nov. 2002, the St. Jude Medical, Inc, Symmetry Bypass System (aortic connector system [ACS]) (St Jude Medical, St. Paul, MN) was used in ten patients. Informed consent was obtained from all patients to use this device. Seven patients had a median sternotomy for multivascular revascularization and three had a post lateral thoracotomy for circumflex revascularization. There were seven men and three women aged 48 to 80 years (mean 64 ± 10 years). Left ventricular systolic function was evaluated by preoperative left ventricular ejection fraction (mean 55% ± 12%). Ten consecutive patients who underwent CABG on the beating heart without CPB, and who received at least one RA graft proximal anastomosis using the St. Jude Medical Symmetry ACS, were evaluated. The internal thoracic artery (ITA) and the RA were simultaneously harvested as a skeletonized pedicle using harmonic ultrasonic scalpel (Fig 1). To prevent radial artery spasms, we continuously administrated diltiazem by intravenous infusion. After the patient had been fully heparinized, the distal vascular stump was divided and phosphodiesterase (PDE) inhibitor (amrinone solution), which is later self-irrigated by blood pressure, was injected. Five minutes later, the RA was harvested as a free graft. The ITAs were used in 9 patients and right gastroepiploic artery (RGEA) grafts were used in 7 patients. The external diameter of the RA graft was assessed to choose the most adequate size of the proximal aortic connector systems in the same manner when using this device for saphenous vein graft.



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  		Fig 1. Radial artery was harvested as a skeletonized graft using ultrasonic scalpel. (A) Skeletonized radial artery. (B) Proximal portion of radical artery.

 
A 4.0-mm sized connector system was used for all grafts in our series. The harvested RA was introduced on the transfer sheath and then guided over the release system. It was then brought over the hooks of the connector with fine-tips forceps. In this matter, the ACS was loaded and prepared for deployment. The aortic wall was punched out using a circular blade and an aortic cutter consisting of an aortic puncture needle with barbs to fix the inner layer of the aorta. The loaded ACS was inserted into the aorta and the internal struts of the aortic connector were deployed, by pushing the button on the handle. The creation of the anastomosis lasted no longer than a few seconds and was accomplished without side-biting of the aorta. The procedure was concluded with distal anastomosis.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Our attempt to use the ACS for proximal anastomosis of the RA was successful in all ten patients. Complete revascularization was achieved in all patients. Figure 2 demonstrates an example of postoperative angiography showing widely patent proximal anastomosis of the RA graft. Mean operating time was 3.2 ± 0.6 minutes and an average of 3.0 ± 0.9 bypass grafts (range, 2 to 5 grafts) were performed. Targeted vessels bypassed were diagonal branch or circumflex coronary system. All patients received the left internal thoracic artery to revascularize the left anterior descending (LAD) artery, and RGEA was used for the right coronary system in seven patients. Two vein grafts were anastomosed to the ascending aorta using the ACS. All connector anastomoses were performed without aortic side clamping, and proximal anastomoses were done first followed by distal anastomoses.



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  		Fig 2. Postoperative angiogram showing a widely patent radial artery graft at the proximal anastomosis.

 
Time to complete the loading and deployment of the RA to the ACS, as well as the mechanical anastomosis, was less than 10 minutes in every case. All RA grafts were patent at the end of the procedure. No patient presented postoperative neurologic complications such as stroke, delirium, or impaired levels of consciousness. There was no postoperative myocardial infarction or abnormal electrocardiographic changes. Postoperative routine angiographic control was performed within ten days. All grafts were widely patent including grafts other than the RA. During the mean postoperative follow-up of 10.3 ± 2.9 months, there was no cardic-related event or any event of angina in any patient.

Distal and proximal portion of the RA were harvested in all patients for histologic study. The specimens were fixed and stained with hematoxylin and eosin. Cross-sections of each specimen were examined. Microscopically, there were no findings of mechanical damage to the RA wall in any specimen.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Several attempts have been reported to develop an alternative device for proximal coronary artery anastomosis, and some devices are now commercially available in the United States and the European Union countries. Eckstein and colleagues [3] describe their experience in the first report on the St. Jude Medical Symmetry ACS and Calafiore and colleagues [1] describe successful clinical application of the prototype of this device.

The St. Jude Medical Symmetry ACS is attractive for off-pump procedure for total arterial revascularization because the anastomoses can be carried out without side-biting of the aorta. This achieves blood pressure stability and avoids major aortic manipulation, therefore minimizes the risk of atheromatous emboli. Atheromatous plaques in the ascending aorta that may be mobilized during aortic manipulation by side-biting clump is the most prominent factor for embolization, contributing to preoperative neurologic morbidity.

However, these commercially available devices are limited to the deployment of saphenous vein grafts, and cannot be used for arterial grafts such as the RA or free internal thoracic arteries because these grafts are normally harvested as a pedicled graft with veins and surrounding tissue. The growing interest in less invasive CABG techniques has generated a need to look for facilitated semiautomatic techniques to create vascular anastomoses even in proximal anastomoses and distal anastomoses. Especially in off-pump CABG, one of the main goals is to achieve the reduction of the manipulation of the ascending aorta, which may be the most important factor in reducing postoperative neurologic complications such as stroke.

On the other hand, the use of arterial conduits and total arterial revascularization are now standard practices in many institutes. Arterial conduits have proved to be accessible and afford great versatility when planning revascularization with multiple grafts, sequential anastomoses, T grafts, and Y grafts. These techniques allow the conservation of available conduits when performing total arterial revascularization. Enthusiasm for these techniques is supported by early-to-midterm data showing excellent patency of RA and reduced in-hospital mortality in patients with multiple arterial grafts [4].

There are, however, some limitations to applying the RA to automatic proximal anastomoses in off-pump CABG. Currently most of the RA grafts for revascularization are harvested in clinical setting as a pedicled graft with accompanying veins. However, these pedicled RA grafts with veins and surrounding tissue cannot be deployed to the transfer sheath of the ACS. Therefore, in our attempt to use an automatic device for proximal anastomosis using arterial grafts, we routinely harvested the RA as a skeletonized graft using ultrasonic harmonic scalpel. With this harvesting technique, the deployment of the RA is as easy as deploying saphenous vein graft to the ACS because the small branches of the RA in between the artery and the veins are sealed by harmonic ultrasonic scalpel, without having to use metallic clips. The detail of the advantages of this harvesting technique is reported elsewhere [5].

Advantages of using a skeletonized RA graft include: (1) minimized risk of kinking or twists in the conduit; (2) extra graft length compared to pedicled grafts; and (3) easy deployment to the ACS without the use of metallic clips. By using RA grafts instead of saphenous vein grafts, we were able to avoid any kinking of the graft at the aortic take-off site, which can be a potential risk of proximal stenosis when using the ACS [5].

In our series, we harvested the RA in a completely skeletonized fashion, and used it as a free graft. In the present study, satisfactory semiautomatic anastomoses were achieved without any complication or any technical difficulties. There was no need to convert to a running technique or a repair by a standard suture.

The long-term result of this aortic proximal connector system is unknown, and long-term follow-up studies are necessary to prove that patency rates are comparable to sutured anastomoses. However, this easy, effective, quick and reliable device produces a uniform anastomosis and appears to be a promising device for further advance in less invasive CABG techniques.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. 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]
  2. Wiklund L., Bugge M., Berglin E. Angiographic results after the use of a sutureless aortic connector for proximal vein graft anastomoses. Ann Thorac Surg 2002;73:1993-1994.[Abstract/Free Full Text]
  3. Eckstein F.S., Bonilla L.F., Englberger L., et al. Minimizing aortic manipulation during OPCAB using the symmetry aortic connector system for proximal vein graft anastomoses. Ann Thorac Surg 2001;72:S995-998.[Abstract/Free Full Text]
  4. Marasco S., Esmore D. A novel method for performing sequential grafts with the radial artery. Ann Thorac Surg 2002;74:1262-1263.[Abstract/Free Full Text]
  5. Taggart D.P., Mathus M.N., Ahmea I. Skeletonization of the radial artery: advantages over the pedicled technique. Ann Thorac Surg 2001;72:298-299.[Abstract/Free Full Text]



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