Ann Thorac Surg 2004;78:1482-1483
© 2004 The Society of Thoracic Surgeons
How to do it
The Use of Aortic Connector as Shunt During Endarterectomy of Innominate Artery
Jaroslav Benedik, MD, PhDa,*,
Viktor Zlocha, MDa,
Jiri Mokrejs, MDa,
Jiri Ferda, MD, PhDb
a Cardiac Surgery, Charles University Hospital, Pilsen, Czech Republic
b Radiology, Charles University Hospital, Pilsen, Czech Republic
Accepted for publication September 5, 2003.
* Address reprint requests to Dr Benedik, Faculty Hospital, Charles University Pilsen–Lochotín, Alej Svobody 80, 304 60 Pilsen, Czech Republic
benedik{at}fnplzen.cz
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Abstract
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The St. Jude aortic connector system (St. Jude Medical, Inc, St. Paul, MN) is being increasingly used for the construction of vein proximal anastomosis in coronary artery bypass grafting. We suggest a possible use of the connected vein as temporary shunt during open endarterectomy of the innominate artery and at the same time as graft for coronary artery bypass grafting.
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Introduction
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The use of mechanical anastomoses devices for construction of proximal anastomoses in coronary artery bypass grafting (CABG) is becoming increasingly popular due to the advantages these devices offer in avoiding manipulation of the ascending aorta [1, 2]. When combined with off-pump procedures, the use of these devices may decrease morbidity rates in patients operated for coronary artery disease (CAD) [3]. A significant stenosis of the innominate artery should be treated by interventional radiology and direct stenting [4], or surgically by bypassing of the diseased vessel or endarterectomy. The combination of stenosis of the innominate artery and CAD warrants a surgical approach.
A 63-year-old man with previous history of myocardial infarction and postinfarction angina was admitted to the neurosurgical department with a compressive cervical fracture. During preoperative examination a weak right radial pulse was found. An angio-computed tomographic (CT) scan found a critical proximal stenosis of the innominate artery (IA). Coronary angiography showed severe stenoses of the left anterior descending and the left obtuse marginal arteries and a complete occlusion of the right coronary artery with good ejection fraction of the left ventricle. The patient was considered a good candidate for off-pump CABG. The operation was performed under general anesthesia with endotracheal intubation and cannulation of the left subclavian vein and left radial artery. After sternotomy the internal mammary artery and the left saphenous vein were harvested. Then preparation of the IA was performed.
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Technique
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A central anastomosis of the vein was constructed by using the St. Jude aortic connector (Symmetry, St. Jude Medical Inc, Minneapolis MN) (ACS). The vein graft was connected via vessel cannula 2,3'' 6 mm tip and perfusion adapter 3/8 barbed on one and male luer on the other end (both DLP Medtronic, Minneapolis, MN), and 5 cm of 3/8 silicone tube by a 12 Fr. femoral cannula (Fem-Flex II, Edwards Lifesciences LLC, Irvine, CA) to the distal IA to serve as a temporary shunt during cross clamping (Fig 1). The IA was opened between the proximal "U" side and the distal straight clamps and endarterectomy was performed with distal fixation of the endarterium. The arteriotomy was then closed with a running Prolene suture. The distal IA was then decannulated and the vein used to bypass the coronary artery. For the second coronary artery, another ACS was used. With the help of the Axius off-pump system (Guidant Corp., Indianapolis, IN) the distal anastomoses of the vein grafts and mammary artery were constructed. The postoperative course was uneventful and the patient was discharged on the sixth postoperative day in good condition. A postoperative CT scan showed good patency of bypasses and innominate artery.
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Fig 1. "Connected" vein graft used as a temporary shunt, which carries blood from the ascending aorta into the innominate artery via small femoral cannula.
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Comment
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The use of ACS for the construction of the proximal venous anastomoses in CABG is increasingly common. Early postoperative angiographic examination in the above patient showed good patency of proximal sutureless anastomoses, confirming good results reported in the medical literature [5]. The use of ACS in combination with off-pump procedures avoids manipulation of the ascending aorta and might indirectly reduce neurologic postoperative morbidity [1–3]. The use of the ACS widens the spectrum of available minimally invasive procedures. In procedures that combine carotid or other arch branch endarterectomy with CABG, the "connected" vein graft might be used instead of a shunt. It is a simple technique that consists of connecting the vein to a small femoral cannula, which is then inserted distally (behind the distal clamp). After endarterectomy, the vein graft is used for bypassing the coronary artery without manipulating the ascending aorta.
The treatment for stenosis of a single arch branch should be accomplished by percutaneous implantation of a stent [5]. Concomitant CAD with need of CABG warrants surgical treatment. In the case reported here, we decided to perform open endarterectomy with excellent results. The same technique could be used in combined carotid and bypass procedures. This technique permits a temporary disconnection of the shunt during open distal endarterectomy of the internal carotid artery in order to clean and suture the distal endarterium.
This very simple technique widened the spectrum of brain protection possibilities during combined coronary and carotid surgery. It could by applied independently on a type of anastomotic device and a type of ongoing CABG (on-off pump). Insertion of ACS is very quick, it takes about 3 to 10 seconds, and only bleeding was considered as an early failure, which can be repaired immediately [2, 3]. The flow through shunt should be controlled optically before insertion, or during shunting by acoustic or other types of flow meter. The combination of IA or carotid endarterectomy and CABG allows the use of aortic connectors as temporary shunts for the prevention of cerebral ischemia.
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References
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- Bonilla LF, Sullivan DJ. New approaches for vascular anastomoses. Curr Interv Cardiol Rep. 2001;3(1):44–49[Medline]
- Eckstein FS, Bonilla LF, Englberger L, et al. The St Jude Medical symmetry aortic connector system for proximal vein graft anastomoses in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2002;123:777–782[Abstract/Free Full Text]
- Eckstein FS, Bonilla LF, 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]
- Jain SP, Zhang SY, Khosla S, et al. Subclavian and innominate arteries stenting: acute and long term results. J Amer Coll Cardiol. 1998;31:63–64
- 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]
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Abstract
Introduction
