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Ann Thorac Surg 2004;78:1878
© 2004 The Society of Thoracic Surgeons

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Correspondence

Graft Occlusion After Deployment of the Aortic Connector Symmetry System: Is Anticoagulation a Necessity?

Department of Cardiovascular Surgery, Heart Center Dresden University Hospital, Fetscherstrasse 76, Dresden, Germany D-01307

monika.weber.hkz_dd{at}t-online.de

To the Editor:

Off-pump coronary artery bypass grafting (OPCAB) procedures still require the use of aortic side-biting clamps for the performance of each proximal anastomosis, and these clamps can lead to aortic injury and occurrence of stroke. The Symmetry aortic connector was developed to reduce vascular trauma to the ascending aorta. This "no-touch" technique may facilitate OPCAB and reduce the incidence of cerebral microemboli and possible stroke in patients by eliminating the need of partial aortic clamping [1].

We have been following the latest developments regarding the Symmetry bypass system aortic connector (St. Jude Medical, St. Paul, MN) for aorta–vein graft anastomoses and refer to articles published recently in leading journals [1–5]. Clinical strategies are based on these data, and we started applying the system in 2002. We have monitored initial results since the introduction of the system.

With reference to two articles [3, 4], we report an additional incident of early graft occlusion after proper deployment of the Symmetry bypass system aortic connector. Our patient underwent quadruple OPCAB. After recurrence of angina at 3 months, angiography was performed and revealed an occlusion of the proximal connector site that probably was due to thrombosis; the distal anastomosis was patent, thus creating an intercoronary shunt. A similar observation concerning the proximal connector site was described by Donsky and co-workers [3]. Traverse and colleagues [2] studied 19 connectors at angiography and found 98% had severe lesions or occlusion. In our opinion, postoperative angiographic data suggest the patency rate of the Symmetry system is poor.

Reasons for early graft occlusion are kinking of the venous graft at the connector site and improper aortic placement of the vein during deployment. The connector must deploy the vein graft at a 90-degree takeoff angle from the aorta, as the proximal portion of the graft can kink as it courses inferiorly toward the heart [2–5]. Thus proper placement of the Symmetry device is essential.

Initial data presented by St. Jude Medical showed complete endothelialization of the connector site after 90 days (Fig 1). With this in mind, and aside from the issue of proper placement, we place patients on an anticoagulate regimen for 3 months to prevent early graft thrombosis at the connector site instead of using coronary stenting.

View larger version (140K): [in this window] [in a new window]   Fig 1. Incomplete endothelialization of connector site after 30 days.

1. 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;72:995–998
2. Traverse JH, Mooney MR, Pedersen WR, et al. Clinical, angiographic and interventional follow-up of patients with aortic–saphenous vein graft connectors. Circulation. 2003;108:452–456[Abstract/Free Full Text]
3. Donsky AS, Schussler JM, Donsky MS, Roberts WC, Hamman BL. Thrombotic occlusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the Symmetry aortic connector system. J Thorac Cardiovasc Surg. 2002;124:397–399[Free Full Text]
4. Reuthebuch OT, Kadner A, Lachat ML, Turina MI. Graft occlusion after deployment of the Symmetry Bypass System. Ann Thorac Surg. 2003;75:1626–1629[Abstract/Free Full Text]
5. Mack MJ, Emery RW, Ley LR, et al. Initial experience with proximal anastomoses performed with a mechanical connector. Ann Thorac Surg. 2003;75:1866–1871[Abstract/Free Full Text]

This article has been cited by other articles:

				P. Bergmann, K. Meszaros, S. Huber, P. Oberwalder, H. Machler, G. Schaffler, R. Rienmueller, and B. Rigler Forty-one-month follow-up of the Symmetry aortic connector system for proximal venous anastomosis J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 23 - 28. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Klaus Matschke Utz Kappert Jens Schneider Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Matschke, K. Articles by Schneider, J. Search for Related Content PubMed PubMed Citation Articles by Matschke, K. Articles by Schneider, J. Related Collections Coronary disease