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Ann Thorac Surg 2008;86:1401-1402. doi:10.1016/j.athoracsur.2008.03.082
© 2008 The Society of Thoracic Surgeons
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Correspondence

New Discussion on an Old Subject: Proximal Anastomosis Markers in Coronary Bypass Surgery

Mustafa Cikirikcioglu, MD, PhDa, Enver Duran, MDb

a Department of Cardiovascular Surgery, University Hospital of Geneva, 24, Rue Micheli-du-Crest, Geneva, 1211 Switzerland
b Department of Cardiovascular Surgery, Faculty of Medicine, Trakya University, Gullapoglu Kampusu, Edirne, 22030 Turkey

(Email: mustafa.cikirikcioglu{at}hcuge.ch; enverduran{at}trakya.edu.tr).

To the Editor:

Olenchock and colleagues [1] revived an important subject on the use of proximal anastomosis markers in coronary bypass surgery. Although late graft patency was not different between marked or nonmarked saphenous vein grafts (SVG), the perioperative myocardial infarction (MI) rate was higher in patients with SVG markers. The article has scientific strengths with its large volume, and prospective and multicenter design.

The importance of proximal anastomotic marker implantation is mainly related to the rate of re-angiography procedures after coronary artery bypass grafting (CABG). The estimated rate for re-angiography procedures after CABG is 10% [2]. The use of proximal anastomotic markers can decrease flouroscopy time, amount of contrast material, and intra-aortic catheter manipulations during re-angiography procedures. Implantation of proximal markers does not increase operative mortality and morbidity [3]. Some series exceed more than 30 years of follow-up without reporting a marker-related major complication [4]. We support the necessity of proximal anastomosis markers for coronary bypass operations, and this technique has been routinely used in our institution at the Department of Cardiovascular Surgery, University Hospital of Trakya, Edirne, Turkey since 2001 [5].

Many different proximal anastomosis markers have been used since the 1970s (ie, hemostatic clips, plastic loops, metal or radiopaque silicon rings, and so forth) [6–8]. All markers except hemostatic clips facilitate the re-angiography procedure. Eisenhauer and colleagues [3] found longer flouroscopy times and higher contrast volumes if the patient had hemostatic clips used for proximal markers with harvested internal mammary arteries [8]. We prefer to use "home made" markers by sternal steel wire. We use different shapes according to the target coronary arteries; for example, a circular shape for the right coronary artery and its branches, a square shape for the left anterior descending artery and its branches, and a hexagonal shape for the circumflex artery branches.

We did not find any information or picture about the type, shape, brand name, and distribution of the markers that have been used in this study. Could the authors share with us which kind of marker or markers were used in this study? If different types were used, was there any difference for the type of markers between patients with or without perioperative MI?

The higher rate of perioperative MI in this study may be related to unequal distribution of marked SVG in the treatment groups. Could the authors share with us the distribution of MI and marked SVG percentages for each treatment group? Were all myocardial infarctions related to territories that were perfused by a marked SVG? Did they reoperate on some patients with proximal markers? If yes, did they encounter fibrosis, narrowing, or any marker-related pathologic changes around the proximal anastomoses?

The use of proximal anastomotic markers is particularly useful for the ambulatory patient population, in which the future angiographies will be performed in different centers. Proximal markers can guide the angiography team even if previous reports are missing or if there is no time to locate reports.

The use of the saphenous vein graft markers is operator-dependent, and many surgeons remain convinced that markers may create complications such as infection, bleeding, perigraft fibrosis, migration, or infarction. For that reason, it is very important to have answers to the previously mentioned questions to understand the role of SVG markers on the perioperative myocardial infarctions.


   References
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 References
 

  1. Olenchock Jr SA, Karmpaliotis D, Gibson WJ, et al. Impact of saphenous vein graft radiographic markers on clinical events and angiographic parameters Ann Thorac Surg 2008;85:520-524.[Abstract/Free Full Text]
  2. Baim DS, Grossman W. Coronary angiographyIn: Grossman W, Baim DS, editors. Cardiac catheterization, angiography, and intervention. Philadelphia, PA: Lea & Febiger; 1991. pp. 192.
  3. Eisenhauer MD, Malik JA, Coyle LC, Arendt MA. Impact of aorto-coronary graft markers on subsequent graft patency: a retrospective review Cathet Cardiovasc Diagn 1997;42:259-261.[Medline]
  4. Nunes CF, Bolooki H. Aorta-coronary graft anastomosis marker: more than 30 years of experience J Thorac Cardiovascular Surg 2005;130:583-584.[Free Full Text]
  5. Cikirikcioglu M, Ozbay G, Duran E. Proximal anastomotic marker use in coronary artery bypass operations Anadolu Kardiyol Derg 2002;2:138-141.[Medline]
  6. Cheanvechai C, Effler DB. A metal ring marker for the proximal end of an aorta-to-coronary artery graft Ann Thorac Surg 1973;15:210-212.[Medline]
  7. Haiderer O, Lansing AM. Wire loops to mark aortosaphenous anastomoses Chest 1973;63:463-464.[Medline]
  8. Peterson L, Mckenzie CR, Ludbrook PA, et al. Value of saphenous vein graft markers during subsequent diagnostic cardiac catheterization Ann Thorac Surg 1999;68:2263-2266.[Abstract/Free Full Text]

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Reply
Stephen A. Olenchock, Jr and C. Michael Gibson
Ann. Thorac. Surg. 2008 86: 1402-1403. [Extract] [Full Text] [PDF]



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S. A. Olenchock Jr and C. M. Gibson
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Ann. Thorac. Surg., October 1, 2008; 86(4): 1402 - 1403.
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