Ann Thorac Surg 2004;78:369-373
© 2004 The Society of Thoracic Surgeons
Our surgical heritage
Circular vascular stapling in coronary surgery
Igor E. Konstantinov, MDa*
a Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
* Address reprint requests to Dr Konstantinov, Division of Cardiovascular Surgery, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1H4, Canada
e-mail: igorkonst{at}hotmail.com
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Abstract
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Stapling devices have been clinically applied to connect blood vessels. The early application of these staplers in cardiovascular surgery, including coronary bypass surgery, was encouraging. With further refinement of suture material, however, vascular staplers became impractical and soon fell into oblivion. With advancement in robotic surgery, these devices might become valuable tools once again. Herein early experience with vascular circular stapling devices is reviewed.
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Introduction
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Stapling is widely used today in various fields of surgery. In fact, it is difficult to imagine modern thoracic or general surgery without surgical stapling devices. Although all modern staplers presently in use are derivatives of Russian staplers developed in the 1950s, it should be emphasized that the history of stapling begins as early as 1908, when the first surgical stapler was applied clinically by Hungarian surgeon Humer Hultl [1, 2]. The history of surgical staplers makes a fascinating story where success and oblivion inseparably interweave [3, 4]. While most staplers evolved into very successful surgical instruments, the less fortunate family of vascular staplers fell into disuse. The evolution of the circular vascular stapler culminated in the development of delicate machinery capable of anastomosing vessels of less than 1.3 mm in diameter. The device was precise and reliable enough for clinical coronary bypass surgery on the beating heart. Ironically, shortly after its successful application in coronary surgery, the circular vascular stapler was abandoned. With proper refinement of suture material and technique, it became much faster and safer to make a suture anastomosis by hand, rather than to use somewhat cumbersome machinery.
It was not until the recent introduction of robotic surgery that some interest in stapled anastomoses was revived. Therefore, it seems timely to review the early experience with circular vascular stapling.
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Development of vascular stapling devices
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It is ironic that the exigencies of warfare often produced technical innovations of great benefit to humankind. During the Second World War, surgeons were gaining vast experience in vascular surgery. Vasilii I. Kolesov was a senior military surgeon of a hospital during the siege of Leningrad. He witnessed all the horrors of war and starvation. About one million people died during the siege of this city. Kolesov himself was starving and cachectic near the end of the siege. When, because of weakness, Kolesov was not able to stay at the operating table, he performed the operation sitting. His surgical team operated daily. Very often there were too many injured to operate on. Therefore, military surgeons thought about suturing devices to facilitate the operation and to reduce the operative time. That led to the construction of Gudov's apparatus and other staplers.
In 1945, Vasilii F. Gudov [5], a mechanical engineer from Leningrad, constructed a "vessel-suturing circular apparatus" (VCA) to anastomose blood vessels (Fig 1).
In his monograph entitled "A New Method of Connecting Blood Vessels," Gudov wrote: "...since 1941, we started research in the field of mechanical suturing of the blood vessels. We kept in mind that this method might be applied for human organ transplantation" [6]. Vladimir P. Demikhov was one of the first to use the vascular stapling device experimentally, and applied these devices for organ transplantation [7, 8]. Working with Pavel I. Androsov in the Sklifosovsky Emergency Institute in Moscow, Demikhov experimentally anastomosed small arteries, including the internal thoracic artery (ITA) in cadavers in the early 1950s [7, 8]. In 1954, Androsov defended his doctoreal dissertation on the subject of the application of vascular stapling devices to anastomose the ITA to the jejunal artery during esophagoplasty. He demonstrated that the ITA might be sutured to one of the jejunal arteries to salvage an antethoracic esophageal replacement whose blood supply has been jeopardized (Fig 2).
Although Androsov did not use the ITA for myocardial revascularization, he demonstrated the technical feasibility to make anastomosis using the ITA graft and to apply VCA clinically for small size vessels [9]. English-reading surgeons probably first became aware of the successful use of stapling machines for vascular anastomoses from the papers of Androsov in 1956, and from the demonstration by Androsov at the Atlantic City Meeting of the American College of Surgeons in 1957 [10]. The instruments came in three basic sizes, each of which had adapters for three sizes within its range, so that anastomoses could be performed in vessels of 1.3 to 15 mm in diameter [9, 11, 12]. In discussing this device after Mark M. Ravitch's presentation in 1959, Francis D. Moore said: "The machinery itself was beautifully made. The staplers were tiny. It did not work out to be a practical device, at least as nearly as we could see...because of the extreme length of time it took to fold the dissected vascular ends back over the cuffs which took the avil and the stapling ring. One had to dissect a lot more vessel length to use the Russian machine than if he did it by direct suture" [10]. Nonetheless, the device was extensively used in Russia in the laboratory and in clinical practice [10, 13–16].
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Fig 1. Gudov's vascular circular stapling apparatus. (Reprinted from Gudov VF, A new method of connecting blood vessels, Moscow, Medgiz, 1950 [6].)
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Fig 2. Schematic picture of Androsov's operation. (Reprinted from Androsov PI, Blood supply of mobilized intestine used for an artificial esophagus, AMA Arch Surg; 1956;73:917–26 [9].)
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In 1953, Andras Bikfalvi in Hungary described his version of the vascular stapler [17]. The Bikfalvi stapler was successfully used in a large number of animal experiments, but unlike the Gudov stapler, it was never applied clinically [4]. In 1958, Kiyoshi Inokuchi in Japan developed vascular staplers for end-to-end and end-to-side anastomoses [18, 19]. In 1959, Inokuchi successfully used the end-to-side stapler in 7 patients requiring splenorenal shunts [19]. These early vascular staplers, including Canadian [20] and American [21] ones, found their best application in the suturing of nonatherosclerotic vessels, since everted flanges of the opposing vessels were needed for vascular anastomosis. The latter made them too cumbersome to apply to atherosclerotic vessels. Further modification and refinement of the staplers were needed.
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Clinical application of vascular staplers in coronary surgery
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Vasilii I. Kolesov is often referred to as the one who performed the first successful coronary artery bypass grafting (CABG) surgery. It should be remembered, however, that the first successful clinical CABG using nonsuture technique was done by Robert H. Goetz in the United States on May 2, 1960 [22, 23]. Goetz used a tantalum ring to connect the ITA to the coronary. Kolesov was the first, and remains the only one, to apply vascular staplers to clinical CABG. Little is known about this successful application of vascular staplers in CABG, and the work that led to it.
On February 25, 1964, Kolesov performed a sutured end-to-end anastomosis between the left ITA and one of the marginal branches of the circumflex artery in a 44-year-old patient. The operation was performed through the left side thoracotomy, the left ITA pedicle was dissected with the aid of magnifying glasses, and an anastomosis was performed with atraumatic needles and 6-0 silk on the beating heart [15, 24, 25]. The patient had no recurrence of angina during 3 years of follow-up. Despite the encouraging initial results, CABG on the beating heart was a challenging operation in the 1960s. Kolesov's team looked for the means to facilitate the creation of the anastomosis. From February 25, 1964, to May 9, 1967, the department of surgery directed by Kolesov was the only place in the world where CABG operations were performed [15]. It is during this time that vascular staplers were used in CABG for the first time. Kolesov's book The Surgery of Coronary Arteries of the Heart, one of the world's first monographs on the subject, is where he described his experience with coronary vascular staplers in much detail [14].
The first application of a modification of Gudov's vascular stapler (VCA-4) was on March 22, 1967, when Kolesov constructed an end-to-end anastomosis between the left ITA and left anterior descending (LAD) artery in a 52-year-old patient with class IV angina [13–15]. Three years later the patient remained free of angina.
On December 11, 1968, Kolesov performed a retrograde left ITA-LAD artery anastomosis with the VCA-4 in a 46-year-old patient with class III angina. Through the median sternotomy incision, the left ITA was dissected proximally and transected near its origin from the left subclavian artery [13, 15]. The patient was free of angina but died 2 years later of a myocardial infarction. An autopsy was not done [13].
On July 10, 1969, Kolesov performed bilateral ITA grafts to the LAD artery and to the right coronary artery using the VCA-4 model with 1.3 mm bushings in a 50-year-old patient with class IV angina and three previous myocardial infarctions. The operation was performed through the left side thoracotomy with transection of the sternum on the beating heart and with cardiopulmonary bypass standby [13, 15]. Although the patient's angina was partially relieved, he died 18 months later of an acute myocardial infarction [13, 15].
Although the VCA-4 produced a perfect anastomosis, it was unsuitable for suturing of coronary arteries with diameters of less than 1.3 mm and required a considerable length of normal vessel on either side for eversion (Fig 3, A).
These obstacles soon were overcome with modifications done by Evgenii V. Kolesov, an associate and son of V. I. Kolesov. Evgenii V. Kolesov included prolonged bushing (VCA-PB, January 10, 1969; Fig 4).
However, V. I. Kolesov was not quite satisfied by this stapler, either. In September 1969, V. I. Kolesov wrote: "In the presence of a small caliber of the heart vessels, it is expedient to use mechanical suture, but, unfortunately, with the present construction of a vessel-suturing apparatuses it is not always possible to apply them in clinical circumstances" [13]. To minimize the eversion of the vascular wall, a modification with a vacuum pump (VCA-VAC, April 17, 1970) was designed by E. V. Kolesov [13, 15] (Fig 3, B, and Fig 5).
The VCA-VAC model was the most reliable [13, 15].
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Fig 3. Extent of the vascular wall eversion with vascular stapling. (A) VCA-4 stapler. (B) Vacuum-facilitated stapler. (1 = vascular wall; 2 = stapler.) (Reprinted from Kolesov VI, et al, Med Tekhnika; 1970;6:24–8 [13].)
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Fig 4. Vascular circular stapler with prolonged bushing applied by V. I. Kolesov and E. V. Kolesov in coronary surgery. (1 = coronary artery; 2 = internal thoracic artery; 3 = incision in the artery; 4 = bushing; 5 = prolonged bushing.) (Reprinted from Kolesov VI, The surgery of coronary arteries of the heart, Leningrad, Meditsina Publishing, 1977 [14].)
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Fig 5. Kolesov's stapler design from the U.S. patent 4,350,160 of September 21, 1982. Figure 1 is a general, partly sectional view of the instrument; Figure 2 is a side elevation view facing an arrow A in Figure 1; Figure 3 is a section taken on the line III-III in Figure 1; Figure 4 is a section taken on the line IV-IV in Figure 1; Figure 5 is a section taken on the line V-V in Figure 1. The instrument is composed of two members: a staple body 1 comprising two halves with semirings 2 (Figs 1 and 2), and termed so because its semirings 2 carry a split staple bush 3 with staples 4 and ejectors 5 of the staples 4 (Figs 1 and 5). The staple body 1 mounts also a mechanism for feeding the staplers 4, provided with levers 6 (Figs 2, 3, and 5). The other member of the instrument is a supporting body 7, comprising two halves with semirings 8 (Figs 1 and 4), and termed so because its semirings 8 carry a split supporting bush 9 with a die for bending the staples 4. Upon having been ejected from the staple bush 3, the staples 4 thrust against the die of the split supporting bush 9 with their legs, which are thus bent into the shape of the letter B to unite the tissue being sutured. The lateral faces of the flanges 10 and 11 have respective openings 14 and 15 communicated with the respective open annular slots 12 and 13. Tubes 16 and 16' (Figs 3, 4, and 5) are connected to said respective openings 14 and 15, said tubes being laid in slots 17 along the halves of staple body 1 and supporting body 7, and are connected with their opposite ends extending from the bodies 1 and 7 outward, to the vacuum device 30. In order to provide fast, accurate, and reliable locking of the staple bush 3 and supporting bush 9 in position, locating rods 18 are made on semirings 2 and 8, while the flanges 10 and 11 have respective sockets 20 (Figs 3 and 4). A lock 19 (Figs 1 and 2) is provided to join the supporting body 1 and the supporting body 7 together. The extending vessel ends are folded back with pincers toward the open annular slots 12 and 13 in the flanges 10 and 11 of the bushes 3 and 9. Folding back of the vessel ends and their approximating the annular slots 12 and 13 are accompanied by vacuum suction, whereby the vessel ends are everted and held by vacuum suction to the bushes 3 and 9, intima outward.
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By 1976, stapled anastomoses were successfully performed with VCA-4, VCA-PB, or VCA-VAC model in 108 (81.8%) patients operated on at the department headed by V. I. Kolesov [13, 15].
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Epilogue
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In 1988, Donald B. Effler, in his editorial to the Journal of Thoracic and Cadiovascular Surgery wrote: "In retrospect, some might say that the Kolesov team in Leningrad acted prematurely because surgical treatment preceded accurate diagnosis (coronary arteriography). In my opinion, this is not the case. The Kolesov saga deserves the recognition of all who are interested in the surgical treatment of coronary artery disease" [26]. The story of coronary vascular staplers remained a forgotten surgical "saga" for almost 3 decades. Most surgeons have never even seen a vascular stapler.
Over the past 5 years, robotic cardiac surgery became realty and was successfully applied to adult and pediatric cardiovascular surgery [27–29]. The advancement of new technology might revive interest in vascular stapling, as those devices are potentially applicable in robotic surgery, including coronary bypass grafting [28] and coarctation of aorta repair [29]. The application of stapling might be easier in children as they have nonatherosclerotic vessels. Besides, the stapling might, at least theoretically, allow normal growth of the stapled anastomosis. It might be easier, however, to apply individual staples or nonpenetrating clips [30], rather that to use the circular stapling devices. The individual clip applier has been commercially available since 1995 as a disposable device (AutoSuture; United States Surgical Corporation, Norwalk, CT).
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Summary
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Once there was a time when the circular vascular staplers were successfully used in clinical surgery and exemplified the cutting edge of advanced surgical technology. That time passed. With modern advances in robotic cardiac surgery, vascular staplers might find a new clinical application. Will these stapling devices, duly perfected, be useful in robotic cardiovascular surgery, notably in coronary bypass surgery? Will recent advances in robotic surgery revive interest in vascular staplers? Or will these devices remain in the past, leaving a fading picture of once fascinating but hopelessly outdated and utterly impractical historical tools? Whether vascular staplers could be used in clinical surgery cannot be questioned. Whether vascular staplers or their modifications will be used in the future cannot be answered. The time will pass. The future will provide the answer to this, for time is the best innovator.
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Acknowledgments
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I am grateful to Drs Dmitri D. Tcherkas, René G. Favaloro, Francis Robicsek, and Kenton J. Zehr for their kind encouragement while I was preparing this article, and to Dr Andrew S. Olearchyk and Renata M. Olearchyk for their most valuable assistance.
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References
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Abstract
Introduction
