Ann Thorac Surg 2007;84:257-258
© 2007 The Society of Thoracic Surgeons
New Technology
Invited commentary
Olivier Chavanon, MD, PhD
Department of Cardiac Surgery, Grenoble University Hospital, Grenoble, BP 217, Cedex 9, France
(Email: ochavanon{at}chu-grenoble.fr).
Once again, a study reports bad results of aortic proximal connectors used to perform anastomosis of saphenous vein graft (SVG) to the ascending aorta. Clearly these techniques are not safe enough to be routinely applied. Connectors were developed with the renewed interest of the off-pump coronary artery bypass graft (OPCAB) procedure and with the exciting perspective of endoscopic and robotic surgery. However, after its initial popularity, OPCAB surgery dramatically decreased, mainly because its indications are now better defined. Ideally the use of proximal devices should allow a fast and reliable connection of a bypass graft to the aorta with minimal manipulation of the aorta, perfect hemostasis, and a safe and easy learning curve with obviously long-term permeability. The Spyder (Medtronic, Minneapolis, MN) connector technique was attractive because it limited the endothelial trauma leading to neointimal hyperplasia, contrary to the previous system. However the interesting study of Biancari and colleagues [1] report that the feasibility of the technique remains unsatisfactory with a notable failure rate. Even if the size of the study is small and the computed tomographic scan assessment is probably not perfect, this article inclines surgeons to stop the use of connectors until some modifications have been done and to encourage a close follow-up of patients who received these devices. The industry will probably continue to work on improvements of these devices, using new concepts or new materials, but from now on surgeons should be cautious before applying these new techniques in the field of coronary artery bypass grafting (CABG). Indeed, if CABG treatments are to still compete with angioplasty treatments for coronary artery disease, surgical results must be as perfect as possible. In this context, the use of a SVG (although probably not the better option except in special cases), should be done at least with a validated and reliable conventional technique. As the usage of SVG should ideally continue to decrease in the future, and given the low rate of the OPCAB procedure, the place of mechanical proximal anastomosis (providing appropriate devices are developed) should be limited to a subgroup of patients (ie, those undergoing the OPCAB technique without the possibility of total arterial grafting using the "no touch technique" of the aorta). The technical challenge remains, but will this group of patients continue to be a sufficient and attractive target market for the industries?
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References
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- Biancari F, Lahtinen J, Ojala R, et al. Spyder aortic connector system in off-pump coronary artery bypass surgery Ann Thorac Surg 2007;84:254-258.[Abstract/Free Full Text]
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