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Ann Thorac Surg 2004;77:1817-1819
© 2004 The Society of Thoracic Surgeons
a Division of Cardiothoracic and Vascular Surgery, Department of Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Biancari, Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, PO Box 21, 90029 OYS, Finland
e-mail: faustobiancari{at}yahoo.it
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Abstract |
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Introduction |
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Recently, a new sutureless anastomotic device (Symmetry Bypass System Aortic Connector, St. Jude Medical Anastomotic Technology Group, St. Paul, MN) has been developed and used largely for anastomosis between the aorta and the saphenous vein graft. The advantages of this device are mainly related to its use during off-pump and minimally invasive coronary artery bypass grafting; this connector seems to be particularly advantageous in case of severely calcified ascending aorta. Along with other research groups [2–7], we have gradually increased use of this new anastomotic device and, from 2001, we have used 103 such devices for proximal anastomosis in 68 patients undergoing off-pump coronary artery bypass grafting. Among these patients, 2 died of complications related to the use of this device.
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Case reports |
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During the morning of the first postoperative day, despite a significant increase of troponin (414 µg/L), the patient was hemodynamically stable, did not require inotropic support, was extubated, and could eat. Supraventricular arrhythmias occurred, but resolved spontaneously. During the afternoon, an episode of ventricular fibrillation occurred. After unsuccessful defibrillation and closed-chest cardiac massage, the sternum was opened and massive hemopericardium was found. A leakage from the proximal anastomosis site, which involved about one fourth of the anastomotic circumference, was found and repaired by suturing in the intensive care unit setting. Despite prompt resuscitative attempts the patient died.
Patient 2
On February 2003, a 71-year-old man with asthma experienced a myocardial infarction as diagnosed at central hospital. Three days later, he was referred to our institution where he underwent emergency coronary angiography because of unstable angina. At angiography, a thrombosis and two stenotic lesions of the left descending coronary artery as well as 50% stenosis of the right coronary artery were found. Echocardiography revealed mild aortic valve regurgitation, and the left ventricular ejection fraction was estimated to be 64%. An off-pump coronary artery bypass operation was planned and performed 5 days later. The left internal mammary artery was anastomosed to the left anterior descending coronary artery. Next, a proximal anastomosis with a saphenous graft was accomplished by using the Symmetry Bypass System Aortic Connector. The arterial pressure at the moment of insertion of the aortic connector system was 90/50 mm Hg. The distal anastomoses were hand-sewn to a left obtuse marginal artery and to the right coronary artery.
The patient made an uneventful recovery and, on the sixth postoperative day, was discharged to a central hospital for postoperative rehabilitation. There, he experienced severe headache for 2 days then, when sitting in the hospital bar, he suddenly collapsed and died. At autopsy, a massive hemopericardium was detected. All the grafts were perfectly patent. At the level of the proximal aortosaphenous anastomosis, a tear was found that led to an aortic dissection involving three fourths of the aortic wall circumference. This aortic tear did not extend much distally and was the site of bleeding. The saphenous vein graft was attached to the anastomotic device, which was in place. However, the lower struts of the aortic connector were detached from the aortic wall in the distal part of the anastomosis, the one involved by the dissecting tear.
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Comment |
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It can be argued that in the first patient, closed-chest cardiac massage may have resulted in the partial detachment of the aortic end of the saphenous graft from the anastomotic device. We have followed the guidelines strictly for loading and deployment of this device, which, in particular, suggest that approximately 0.5 mm of the vein graft should be positioned over the hooks of the aortic connector. Indeed, after the occurrence of the first case of anastomotic leakage, we have positioned 1 to 2 mm of the vein graft over the device hooks to decrease the potential risk of such a complication. We believe that this complication was not related to incorrect implantation of the device. Moreover, even if the leakage had been secondary to resuscitation maneuvers, the device was revealed to potentially fail in connection with such events.
In the second patient, aortic dissection was clearly shown to have developed from the site of the proximal anastomosis. The device was in place and only its lower struts were partially detached from the aortic wall, likely because this anastomosis was involved by the aortic tear. However, aortic cannulation, cross-clamping, side-clamping, and hand-sewn anastomosis could initiate aortic dissection. Indeed, all these alternative techniques are more likely to cause more aortic trauma than the aortic connector device.
Although evolving technology will provide new possibilities to improve the current techniques and results of cardiac surgery, a cautious evaluation of new techniques remains of great importance in order to establish safety and to improve potential limits. Aware of the results of previous studies and of our experience with the device, we continue to use the Symmetry Bypass System Aortic Connector for patients with a severely diseased ascending aorta when aortosaphenous anastomoses cannot be avoided or substituted with alternative techniques. We assume that the potential benefits of the Symmetry device in such cases outweigh the rare occurrence of device-related complications. When the ascending aorta is not diseased and until new, safer anastomotic devices are introduced, we prefer to use aortic side-clamping and hand-sewn anastomoses.
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  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]
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 T. Puehler, S. Fraund-Cremer, J. Cremer, and A. Boening Successful six-year follow-up of a sutureless device for proximal anastomoses in a severely calcified ascending aorta Interactive CardioVascular and Thoracic Surgery, August 1, 2008; 7(4): 670 - 672. [Abstract] [Full Text] [PDF]
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A. Mommerot and L. P. Perrault Use of Aortic Connector Device for Porcelain Aorta: To Touch or Not to Touch? That is the Question Ann. Thorac. Surg., July 1, 2007; 84(1): 355 - 355. [Full Text] [PDF]
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