Ann Thorac Surg 2005;80:353-354
© 2005 The Society of Thoracic Surgeons
How to do it
Hammock-like Graft-Holding Method Using a Cotton Bandage in Off-Pump Coronary Artery Bypass
Hidefumi Obo, MD*,
Nobuhiko Mukohara, MD,
Masato Yoshida, MD,
Tsutomu Shida, MD
Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Hyogo, Japan
Accepted for publication February 6, 2004.
* Address reprint requests to Dr Obo, Hyogo Brain and Heart Center, Saisyou Kou 520, Himeji, Hyogo, 670-0981, Japan; (Email: hobo{at}hbhc.jp).
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Abstract
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A simple and inexpensive new graft-holding method is described. This method requires only a cotton bandage to hold the skeletonized graft in off-pump coronary artery bypass. A wet cotton bandage hung between the blades of a retractor can hold grafts in an atraumatic fashion at the center of the operating field and facilitate anastomosis during off-pump coronary artery bypass.
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Introduction
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Recently, off-pump coronary artery bypass with multiple arterial grafts—such as in situ skeletonized internal thoracic artery (ITA) [1], in situ skeletonized gastroepiploic artery (GEA) [2], composite grafts of the radial artery, or free ITA—has been performed with increased frequency. Because these grafts easily flutter and parch in the wind of the blower and are vulnerable to compression injury by forceps, graft holding is one of the most important issues during anastomosis. Therefore, we developed a simple and inexpensive atraumatic method to hold arterial, especially skeletonized, grafts during anastomosis by using a saline-soaked cotton bandage.
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Technique
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We usually use a 4-cm-wide, 120-cm-long cotton bandage for the Spooner technique [3]. We appropriate this bandage for graft holding. The bandage is folded to half-length, and its edge is clipped on the drape near the blade of the retractor. One side of the bandage is hung between the blades of the retractor like a hammock. The graft is placed on this hammock and then covered by the rest of the bandage. By pouring saline on the bandage, the graft-holding power is tightened by the weight of the wet bandage.
For anastomosis of a composite graft, the bandage is hung over the ascending aorta. The upper part of the skeletonized ITA and the proximal part of the radial artery are placed on the center of the bandage, and the remainder of the bandage is placed over the grafts. The upper part of the bandage just above the grafts is fenestrated roundly, and saline is poured over the area. Both grafts are stabilized in the same field by this method, thus allowing composite graft anastomosis to become feasible (Fig 1).
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Fig 1. Anastomosis of the internal thoracic artery (ITA) and radial artery (RA). The cotton bandage is clipped on the drape by hemostatic forceps and hung between the blades of the retractor. The grafts are sandwiched between the bandage and saturated with saline.
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For anastomosis of the ITA and left anterior descending artery, the bandage is hung close to the right ventricular outflow tract while attention is paid not to let the bandage touch the heart but to sandwich the distal end of the ITA. The upper part of the bandage is incised in a V shape to expose the ITA. After 3 stitches of continuous monofilament suture are placed around the heel side of the anastomosis, the bandage is removed, and the graft is pulled down to the anastomosis site (Fig 2).
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Fig 2. In case of internal thoracic artery (ITA) to left anterior descending artery (LAD) anastomosis (A) or gastroepiploic artery (GEA) to posterior descending artery (PD) anastomosis (B), the bandage is hung close to the target vessel and incised in a V shape.
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For anastomosis of the GEA and right coronary artery, the apex of the heart is raised by using a heart positioner, and the bandage is hung over the diaphragm. The GEA is passed through the split diaphragm and placed on the bandage facing the anastomosis site of the right coronary artery. Incision in the bandage and placement of stitches proceed in the same manner as for left anterior descending artery anastomosis.
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Comment
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Although several graft-holding methods in coronary artery bypass grafting have been reported previously [4–7], many of these techniques were developed to hold pedicles of the grafts and are not suitable for skeletonized grafts. Moreover, these techniques require some special handmade apparatus. The merits of the method described here are as follows. First, this method is simple, and there is no need to prepare a special apparatus. Just a bandage is required. Second, by folding the wet bandage, skeletonized grafts can be held in an atraumatic fashion and can be kept wet. Third, by hanging the bandage between the blades of the retractor, the graft can be settled in the center of the operating field. In case of an anastomosis that involves the circumflex artery, the graft cannot be placed near the anastomosis site, and stitches longer than 45 cm, which we usually use, may be required. This may be one of the demerits of this method.
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References
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- Higami T, Maruo A, Yamashita T, et al. Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel J Thorac Cardiovasc Surg 2000;120:1142-1147.[Abstract/Free Full Text]
- Asai T, Tabata S. Skeletonization of the right gastroepiploic artery using an ultrasonic scalpel Ann Thorac Surg 2002;74:1715-1717.[Abstract/Free Full Text]
- Spooner TH, Hart JC, Pym J. A two-year, three institution experience with the Medtronic Octopussystematic off-pump surgery. Ann Thorac Surg 1999;68:1478-1481.[Abstract/Free Full Text]
- Mobin-Uddin K, Pleasant R. Vascular anastomosis with Mobin-Uddin vein/graft holder Ann Thorac Surg 1986;42:591-592.[Abstract]
- Watanabe G, Misaki T. Internal thoracic artery graft holder for coronary artery bypass grafting Ann Thorac Surg 1994;57:492-493.[Abstract]
- Yokoyama H, Tanaka S. Simple arterial graft holder for coronary artery bypass grafting Ann Thorac Surg 1995;59:533-534.[Abstract/Free Full Text]
- Satoh H, Miyamoto Y, Koyama M, et al. Internal thoracic artery holder for coronary artery bypass grafting Ann Thorac Surg 1996;61:1269-1270.[Free Full Text]
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Abstract
Introduction
