Ann Thorac Surg 2008;86:317-319. doi:10.1016/j.athoracsur.2008.01.024
© 2008 The Society of Thoracic Surgeons
How To Do It
An Arterial and Venous Graft Holder for Coronary Artery Bypass Grafting
Huseyin Okutan, MD*
Department of Cardiovascular Surgery, Suleyman Demirel University Medical School, Isparta, Turkey
Accepted for publication January 8, 2008.
* Address correspondence to Dr Okutan, Bahcelievler M. 102 C. 59/1 Daloglu A. K:2 D:6, Isparta, 32200, Turkey (Email: hokutan{at}cardio.sdu.edu.tr).
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Abstract
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An innovative arterial and venous graft holder has been developed for use during proximal and distal anastomosis in coronary artery bypass grafting. The device consists of a flexible arm and a handle. The handle in turn is composed of three parts: (1) a T-shaped body, (2) an atraumatic clip for holding the graft, and (3) a coronary probe attached by an adjustable fixation screw to the body. The handle can be used to easily hold the graft either by an assistant or attached to a flexible arm. The flexible arm can be used while attached to a standard sternal retractor or a railway sternal retractor. It facilitates opening the heel of the graft and stitching the most difficult angle of the anastomosis. This new instrument provides excellent exposure and a more comfortable anastomosis.
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Introduction
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Many cardiac surgeons commonly use microvascular forceps to hold and open the orifice of the graft during coronary artery bypass grafting (CABG). However, this traditional technique has a number of pitfalls such as inadequate exposure, graft injury, and slips of the graft from the forceps during anastomosis.
It is well known that some skilled assistance is required during anastomosis. Therefore, various devices have been developed for facilitating anastomosis in CABG [1–6]. This article describes an innovative new arterial and venous (A-V) graft holder (patent pending), a device that is useful during proximal and distal anastomosis of arterial and venous grafts in on-pump or off-pump CABG.
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Technique
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The A-V graft holder consists of a flexible arm and a handle for holding the graft. The flexible arm is multi-jointed and attached to a standard sternal retractor. Alternatively, it can be used with a railway sternal retractor (Fig 1). The handle consists of a coronary probe attached by an adjustable fixation screw to a T-shaped body as well as an atraumatic clip for holding the graft (Fig 2A). Both clip blades were designed to be atraumatic with an opposite opening angle (Fig 2B). When the clip holds the end of the graft, the coronary probe can be gently inserted into the graft without causing endothelial injury. Uniform olive tip coronary probes (available in 1 mm, 1.5 mm, 2 mm, and 2.5 mm sizes) allow for easy, atraumatic insertion into the graft. Also, a fork-shaped coronary probe was designed for venous grafts with large diameters (Fig 2C). The handle, flexible arm, coronary probes, and railway sternal retractor are made of chrome and are autoclavable.
During anastomosis, the graft is properly trimmed and the handle is held adjacent to the end of the graft. The coronary probe with an accurate diameter is selected and gently inserted into the arterial or venous graft (Fig 3A). The assistant holds the handle between his or her thumb and index finger, and approximated to the coronary arteriotomy. Alternatively, the handle can be attached to a flexible arm. By bending and anchoring the shape of the flexible arm, the handle is easily connected to the tip of the arm. The suture is started from outside-in on the graft, and then inside-out on the artery, working into the heel from the surgeon's side, and then out from the heel on the side opposite the surgeon (Fig 3B). In the traditional technique, two opposite sides of the graft may be inverted inside. This can also result in suboptimal exposure and prolonged anastomosis time. Therefore, back wall suturing is an important risk for endothelial injury and anastomosis failure. The use of the A-V graft holder during anastomotic construction may protect against back wall suturing at a minimal risk of endothelial injury.
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Fig 3. The handle is held adjacent to the end of the graft. (A) The edge of the heel portion is opened with the insertion of the coronary probe, which facilitates needle insertion. The suture is started from outside-in on the graft, and then inside-out on the artery, working into the heel from the surgeon's side, and then out from the heel on the side opposite the surgeon. After the coronary probe has been removed, (B) the graft is lowered into position and the suture is continued to the toe. (C) The redundant graft is cut in-line with the no-touch technique. (D) Anastomosis is completed in routine fashion.
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The A-V graft holder for CABG can expose the sides of the conduit and provide an excellent anastomosis field. By using the A-V graft holder, it is possible to open the heel of the conduit and stitch the most difficult angle of the anastomosis under optimal exposure. Several sutures (five or seven) are then placed with the conduit in the air, coming around the heel toward the near side. After the probe is removed from the inside of the graft, the conduit is then parachuted down onto the arteriotomy. The handle for CABG is released and the anastomosis is then completed with the no-touch technique (Figs 3C and 3D).
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Comment
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Several graft holders have been reported to accelerate and ensure a reliable anastomosis for CABG [1–6]. These instruments have been widely used in various cardiac centers around the world. The innovative device described in this article has several advantages. It could be used during distal and proximal anastomosis of both arterial and venous grafts in off-pump or on-pump bypass. It is well known that the use of a graft holder during CABG has three technical disadvantages. First, the graft often slips from the graft holders during anastomosis. Therefore, by holding the graft between atraumatic clip blades of the presented A-V graft holder with adequate grasping power, the graft can be held in an atraumatic fashion with minimal risk of slips.
Second, most graft holders are designed for use with either arterial or venous grafts but not both. This limitation is due to the different diameters of arterial and venous grafts. The new instrument can be used for grafts of different diameters thanks to its ability to fit coronary probes of different sizes. The arterial graft for CABG has a smaller diameter compared with the venous graft, so the coronary probe is selected in-line with the diameter of the graft. An accurate-sized coronary probe with an outer diameter smaller than the inner diameter of the arterial graft should be selected. If this is not done, endothelial injury may occur during insertion of the coronary probe. Moreover, the aim of the use of the coronary probe is to prevent inversion of surfaces of the graft to inside and back wall suturing, but not mechanical dilation of the graft.
Finally, holding the graft may cause injury of the graft intima. Handling of the graft while completing anastomosis is minimized by the no-touch technique advocated by Galvin [7]. To use this technique, it is necessary to make a cut near the end of the graft before completing the suturing around the toe. The innovative A-V graft holder described here enables the surgeon to perform the no-touch technique without fear of endothelial injury.
Successful proximal and distal anastomosis for CABG is dependent on good exposure and skillful assistance. The new graft holder provides excellent visualization of the anastomotic site, prevents back wall suturing and endothelial injury, and does not require skillful assistance. In addition, because these coronary probes were originally designed with different sizes for safe placement in grafts, the risk of endothelial injury is minimized. The new graft holder can be used by coronary surgeons with safety.
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Acknowledgments
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Supported by the Scientific Research Foundation (117/2007), Bilimsel Arastirma Fonu, Suleyman Demirel University.
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References
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- Galvin IF. Mammary artery grafts: a new no-touch technique for anastomosis Ann Thorac Surg 1991;51:500-503.[Abstract/Free Full Text]
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Abstract
Introduction
