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Ann Thorac Surg 2008;86:1873-1877. doi:10.1016/j.athoracsur.2008.06.047
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Shunt or Snare: Coronary Endothelial Damage due to Hemostatic Devices for Beating Heart Coronary Surgery

Herbert Hangler, MDa,*, Ludwig Mueller, MDa, Elfriede Ruttmann, MDa, Herwig Antretter, MDa, Kristian Pfaller, PhDb

a Department of Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
b Section for Histology and Embryology, Medical University Innsbruck, Innsbruck, Austria

Accepted for publication June 9, 2008.

* Address correspondence to Dr Hangler, Department of Cardiac Surgery, Medical University Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria (Email: herbert.hangler{at}i-med.ac.at).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Occlusion of coronary arteries during off-pump coronary bypass operations bears the potential for endothelial injury. The aim of this study was to elucidate the effects of hemostatic devices on the beating heart in human coronaries by means of scanning electron microscopy.

Methods: The coronary arteries of 9 patients with dilated cardiomyopathy and 13 with ischemic heart disease undergoing heart transplantation were handled with intracoronary shunts as well as external snaring techniques on a beating heart, after cannulation but before starting cardiopulmonary bypass. Adjacent noninstrumented coronary artery segments served as controls. Integrity of endothelial lining was observed with scanning electron microscopy.

Results: Nearly all coronary artery segments manipulated with a shunt exhibited a severe injury with extensive endothelial denudation. Endothelial injury was significantly higher after manipulation with intracoronary shunts compared with external occlusion devices (p < 0.001) or control specimens (p < 0.001). Plaque rupture was apparent in 3 samples.

Conclusions: Manipulation of human coronary arteries during off-pump operations leads to endothelial denudation and plaque rupture. From this investigation we conclude that insertion of intracoronary shunts during beating heart operations leads to severe endothelial denudation in human coronary arteries. We therefore recommend using shunts selectively in cases where critical ischemia or technical difficulties due to anatomic conditions are expected during anastomosis. The clinical significance of these structural damages has to be further investigated with clinical trials.


   Introduction
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 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
As a result of new devices and the development of surgical techniques for exposure and stabilization [1–4], multivessel coronary artery bypass grafting without cardiopulmonary bypass (OPCAB) has emerged in the past years, although there are conflicting data whether postoperative morbidity and mortality is lower than in on-pump procedures [5–12]. During OPCAB, control of bleeding from the target vessel is either achieved by external compression with loops and sutures or insertion of an intraluminal shunt. As shown in animal models, the application of hemostatic devices may be harmful to the coronary endothelium [13]. Intimal hyperplastic responses can result in a risk for consequent stenosis in the region of local occlusion.

The aim of this study was to point out the effects of commonly applied coronary occlusion techniques. The integrity of the endothelial coating in human coronary arteries was investigated with scanning electron microscopy (SEM) after manipulation on a beating heart.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Study Groups and Surgical Technique
The study was approved by the local Ethics Committee, and all patients gave informed consent before their inclusion into the study.

Coronary artery segments of patients undergoing orthotopic heart transplantation for dilated cardiomyopathy (DCMP, group I, n = 9) or ischemic coronary heart disease (ICMP, group II, n = 13) were handled with hemostatic devices on the beating heart, after cannulation but before cardiopulmonary bypass (CPB) was started in 18 patients. In 4 patients CPB had to be started due to hemodynamic instability, but without fully unloading the heart. The manipulations were done on segments 1 and 2 of the right coronary artery (RCA) and segments 6 and 7 of the left anterior descending coronary artery (LAD). The demographic data of the study population are provided in Table 1.


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  		Table 1 Demographic Data of Patients Undergoing Occlusion of Coronary Arteries
 
Sixteen Anastaflo RMI intravascular shunts (Research Medical Inc, Midvale, UT) were placed into the coronary artery using the shunt shuffle technique [14]. The size of the shunt was chosen by evaluating the outside diameter with a probe after dissecting the coronary artery but before arteriotomy. The shunt was chosen one size smaller than the measured outer diameter of the coronary artery.

Coronary arteries were occluded by being encircled with a 3-0 polypropylene suture, buttressed with a piece of silicone tubing (n = 9) or a Teflon felt pledget (DuPont, Wilmington, DE; n = 10) as abutment, and lashed with a soft silicone tube. Ten coronaries were double-looped with a Retract-o-Tape Air cushion vascular loop (Quest Medical Inc, Allen, TX). In addition, 13 MyOcclude vessel occlusion devices (Vascular Therapies, USSC, Elancour, France) and 8 bulldog clamps (19-8097, Codman, Raynham, MA) were applied for local coronary occlusion. Uninstrumented segments of 31 coronary arteries served as controls. Table 2 provides the occlusion methods applied according to the disease and manipulated coronary arteries.


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  		Table 2 Occlusion Methods Applied According to Manipulated Coronary Arteries and Disease
 
Tissue Procurement
Immediately after the diseased recipient heart was excised, the coronary arteries were perfused for 10 minutes with 2.5% glutaraldehyde in 0.1M cacodylate buffer (pH 7.4) at a monitored pressure of 120 mm Hg through a perfusion cannula (P616, Stöckert, Munich, Germany) inserted into the left or right coronary ostium. In this way the endothelium was fixed in situ at a physiologic pressure before being further processed for SEM. Subsequently the vessels were carefully dissected free from the adherent epicardial tissue in a no-touch technique under x12 magnification and cut transverse, 5 mm apart from the occlusion area on each side. Control samples were taken from the adjacent not instrumented areas of the same coronary artery.

Preparation of the Coronary Arteries for SEM
The coronary artery cylinders were cut longitudinally, pinned on cork plates, and postfixed in 1% osmium tetroxide, further on dehydrated in a graded ethanol series, and then underwent critical-point drying (Bal Tec CPD 030, Balzers, Liechtenstein). Samples were dried and mounted on specimen stubs using colloidal silver and coated with 15nM gold (Bal Tec MED 020, Balzers). The entire endothelial surface of each specimen was examined with a DSM 982 Gemini SEM (Carl Zeiss Inc, Oberkochen, Germany), operated at 5 kV.

Histologic Investigation
Histomorphologic changes of the endothelial layer were classified into four grades:

Grade 0: the entire surface is covered by intact endothelial cells with tight intercellular attachment (intact endothelial layer) (Fig 1);
Grade I: dehiscent intercellular junctions of endothelial cells;
Grade II: detachment of several endothelial cells (minor injury);
Grade III: focal areas devoid of endothelial cells (moderate injury) (Fig 2); and
Grade IV: expansive local endothelial denudation with subendothelial tissue exposed (severe injury) (Fig 3).


Figure 1
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  		Fig 1. Scanning electron micrographs of intact human coronary artery endothelium. Panels A (x200) and B (x500) show morphologically intact endothelium. Spindle-shaped endothelial cells (*) are orientated in the direction of blood flow. Panel C (x500) shows morphologically intact endothelium. Whirl-like arrangement of endothelial cells (*) downstream a coronary artery stenosis. Panel D (x100) shows morphologically intact endothelium. Polygonal-shaped endothelial cells (**) are covering a coronary artery plaque.

 

Figure 2
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  		Fig 2. Focal localized endothelial denudation (grade III, moderate endothelial injury) after vessel loop occlusion (x200). The subendothelial tissue is exposed (#) to the blood stream. Intact endothelial layer (*) is seen beside the injured area of the human coronary artery.

 

Figure 3
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  		Fig 3. Endothelial denudation (grade IV, severe endothelial injury) after manipulation with an intravascular shunt (x200), with the subendothelial tissue exposed (#) to the blood stream. Residual endothelial cells (*).

 
The specimens were examined by a histologist experienced in SEM, blinded to all data.

Statistical Analysis
Data were stored in a computerized Excel database (Microsoft Inc, Redmond, WA), and statistical assessments were performed using SPSS software (SPSS Inc, Chicago, IL). Comparisons between groups were made using the {chi}2 test or the Fisher exact test, where appropriate. A value of p < 0.05 was considered to be significant.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
None of the controls exhibited a moderate or severe (grade III and IV) endothelial injury. There was no statistical significant difference in the endothelial lesions between the DCMP and ICMP study groups before or after instrumentation with hemostatic devices.

After snaring with polypropylene sutures or application of bulldog clamps and vessel loops, there was a significant endothelial damage compared with controls (p < 0.001). Only the MyOcclude device did not harm the endothelium significantly (p = 0.098). All coronary artery segments manipulated with a shunt exhibited a grade III (n = 5) or grade IV (n = 61) injury with nearly complete denudation of the endothelial layer (Table 3). Endothelial injury was significantly more intense after manipulation with intracoronary shunts compared with controls (p < 0.001) or external occlusion devices (p < 0.001).


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  		Table 3 Endothelial Injury According to the Vascular Occlusion Method Compared With Uninstrumented Controls
 
Three plaque ruptures were encountered after coronary artery occlusion from the outside, but none in the shunt group. No dissection was apparent after shunt insertion or snaring.


   Comment
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 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Manipulating coronary arteries with hemostatic devices during OPCAB bears the risk of endothelial injury with subsequent coronary artery stenosis [15–17] and collateral damage such as septal myocardial infarction [18], septal branch right ventricular fistula [19], and distal embolization of atheromatous debris [20]. Previous studies analyzing the effects of hemostatic devices on coronary endothelial function and morphology have been performed in animal coronary arteries. In organ chamber experiments, a higher degree of endothelial dysfunction was noted after an intraluminal shunt was inserted compared with compression of the coronary artery from the outside [21–23]. This is consistent with our findings exhibiting severe endothelial denudation of human coronary arteries subsequent to shunt placement. Demaria and colleagues [24] found a decrease in endothelial dysfunction when undersized shunts were launched into pig coronary arteries. In contrast, in the presented study there was no reduction of endothelial injury with undersized (leaking) shunts [24].

There is experimental and clinical evidence that left ventricular function and myocardial ischemia is reduced when intraluminal shunts are used during off-pump left internal mammary artery to LAD anastomosis [25, 26]. In addition Menon and colleagues [27] investigated 35 patients undergoing minimal invasive direct coronary artery bypass grafting (MIDCAB) either with snaring or inserting a shunt into the LAD beyond a high-grade coronary artery stenosis. A superior early patency rate of the anastomosis with less need for reinterventions up to 6 months postoperatively was reported compared with local external occlusion of the LAD [27]. This may be in part contrary to our results because after denudation of the endothelium in the region where the occluding bulbs of the shunts are situated, an unfavorable arterial remodelling process with consequent target coronary artery stenosis could be presumed. The better patency rate in MIDCAB of the shunted group in the Menon and colleagues' [27] study has been attributed to a minor technical anastomosis failure rate. However, just a single study by Yeatman and colleagues [28] compared shunt insertion with snaring in multivessel OPCAB. Despite improvement of intraoperative hemodynamic indicators, there was no significant difference in clinical short-term outcome. A longer follow-up of these patients by means of angiographic or multislice computed tomography studies would be of importance in this setting [29].

Furthermore, in the "response to injury hypothesis" [30], endothelial cell injury such as focal denudation or dysfunction of endothelium is considered to be a key event in the evolution of atherosclerosis by inducing growth factor production, attachment of macrophages, and monocytes. The loss of endothelial cell coverage due to hemostatic devices, as demonstrated in the presented study, may be healed by regenerating endothelium. Nevertheless, regenerated endothelium is also dysfunctional, because these endothelial cells have lost some of their ability to release endothelium-dependent relaxing factors and are no longer able to prevent aggregating platelet-induced contraction [31]. Occurrence of vasospasm and atherosclerosis may be accelerated in these areas covered by regenerated endothelial cells. Although, as demonstrated in this study, endothelial injury is less after manipulation with external occlusion devices compared with intracoronary shunts, it is still considerable.

Moreover, when snaring sutures are placed in an area of the coronary artery with severe atherosclerotic disease and the circumferential tension on lipid-laden plaques exceeds its tensile strength, it will rupture and expose atheromatous material, the most thrombogenic component of a plaque, to the blood stream. Acute coronary syndromes, depending on the extent of thrombus formation or embolization of atheromatous debris, may occur [32]. In addition, Gerola and colleagues [33] have shown compression and buckling of the elastic lamellae with medial fractures when snares were applied to a region with marked atherosclerotic disease [33].

Another concern is dissection of the coronary artery due to manipulation with hemostatic devices, but has so far been reported solely by Izutani and Gill [34]. We did not observe this in our investigation.

Interestingly, we found less endothelial injury after local occluding of the coronaries with the Myocclude device. Potential reasons for the lesser damage with this occlusion device can only be speculated. It may be partly due to the preset clamping force of the device or because the coronary artery is not encircled and therefore the wall stress due to the compression is less.

In this study we measured the outer diameter of the coronary artery with a probe to evaluate the adequate shunt size. The shunt was chosen one size less than the probe size. However, if we had evaluated the shunt size by probing of the internal diameter, there would have been the potential of additional endothelial damage that would have considerably influenced the results of the study. It could be argued that using an undersized shunt would lead to a lesser degree of endothelial damage than inserting an equally sized or oversized shunt. Our investigation, however, found no statistically significant difference in endothelial injury with leaking compared with leakproof shunts. In addition the number of shunt insertion attempts (11 one time, 5 two times) had no statistically significant influence on the degree of endothelial injury.

Manipulation of human coronary arteries during OPCAB leads to endothelial denudation and plaque rupture. From this investigation we conclude that the insertion of intracoronary shunts during beating heart operations leads to severe endothelial denudation in human coronary arteries. We therefore recommend that shunts be used selectively in cases where critical ischemia or technical difficulties due to anatomic conditions are expected during anastomosis. The clinical significance of these structural damages has to be further investigated with clinical trials.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Jansen EW, Borst C, Lahpor JR. Coronary artery bypass grafting without cardiopulmonary bypass using the octopus method: results in the first one hundred patients J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
  2. Dullum MK, Resano FG. Xpose: a new device that provides reproducible and easy access for multivessel beating heart bypass grafting Heart Surg Forum 2003;2:113-117.
  3. Ricci M, Karamanoukian HL, D'Ancona G, Bergsland J, Salerno TA. Exposure and mechanical stabilization in off-pump coronary artery bypass grafting via sternotomy Ann Thorac Surg 2000;70:1736-1740.[Abstract/Free Full Text]
  4. Akpinar B, Guden M, Sagbas E, Sanisoglu I, Aytekin V, Bayindir O. Off-pump coronary artery bypass grafting with use of the octopus 2 stabilization system Heart Surg Forum 2000;3:282-286.[Medline]
  5. Bull DA, Neumayer LA, Stringham JC, Meldrum P, Affleck DG, Karwande SV. Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting: does eliminating the pump reduce morbidity and cost? Ann Thorac Surg 2001;71:170-173.[Abstract/Free Full Text]
  6. Kim KB, Lim C, Lee C. Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts Ann Thorac Surg 2001;72:S1033-S1037.[Abstract/Free Full Text]
  7. Thalmann M, Trampitsch E, Sorre CH, Wandschneider W. OPCAB: reducing the perioperative risk avoiding extracorporeal circulation in CABG surgery Eur Surg 2003;35:327-329.
  8. Puskas JD, Williams WH, Duke PG. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting J Thorac Cardiovasc Surg 2003;125:797-808.[Abstract/Free Full Text]
  9. Mächler H, Rigler B. Off-pump coronary grafting is superior to standard on pump coronary bypass techniques Eur Surg 2004;36:187-189.
  10. Fuchs U, Sivitanidis E, Reichert J, Laczkovics A. What can be learned from the postoperative angiographic result in off-pump coronary artery bypass surgery on the beating heart Eur Surg 2004;36:180-184.
  11. Kim KB, Lim C, Lee C. Off-pump coronary artery bypass may decrease the patency of saphenous vein grafts Ann Thorac Surg 2001;72:S1033-S1037.[Abstract/Free Full Text]
  12. Fritz MK, Wiebalck A, Khargi K, Reber D, Buchwald D, Laczkovics AM. Does off-pump coronary artery bypass surgery reduce morbidity and mortality in high risk patients? Eur Surg 2004;36:363-367.
  13. Perrault LP, Desjardins N, Nickner C, Geoffroy P, Tanguay J, Carrier M. Effects of occlusion devices for minimally invasive coronary artery bypass surgery on coronary endothelial function of atherosclerotic arteries Heart Surg Forum 2000;3:287-292.[Medline]
  14. Patel NC, Pullan DM, Fabri BM. ‘Shunt shuffle'-a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass Eur J Cardiothorac Surg 2002;21:1121-1122.[Abstract/Free Full Text]
  15. Pfister AJ, Zaki SM, Garcia J, Mispireta LA. Coronary artery bypass without cardiopulmonary bypass(Comment Gundry) Ann Thorac Surg 1992;54:1085-1092.[Abstract/Free Full Text]
  16. Alessandrini F, Gaudino M, Glieca F. Lesions of the target vessel during minimally invasive myocardial revascularization Ann Thorac Surg 1997;64:1349-1353.[Abstract/Free Full Text]
  17. Pagni S, Qaqish NK, Senior DG, Spence PA. Anastomotic complications in minimally invasive coronary bypass grafting Ann Thorac Surg 1997;63(6 suppl):S64-S67.[Medline]
  18. Splittgerber FH, Minale C. Septal myocardial infarction: a complication of coronary artery stay sutures Ann Thorac Surg 1993;56:400-401.[Free Full Text]
  19. Tanemoto KT, Kuroki K, Kanaoka Y, Murakami T. Septal branch right ventricular fistula: a complication in coronary artery snaring Ann Thorac Surg 1999;68:246-248.[Abstract/Free Full Text]
  20. Izzat MB, Yim AP, El Zufari MH. Snaring of a coronary artery causing distal atheroma embolization Ann Thorac Surg 1998;66:1806-1808.[Abstract/Free Full Text]
  21. Chavanon O, Perrault LP, Menasche P, Carrier M, Vanhoutte PM. As originally published in 1996: Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations Ann Thorac Surg 1999;68:1118-1120.[Free Full Text]
  22. Perrault LP, Menasche P, Wassef M. Endothelial effects of hemostatic devices for continuous cardioplegia or minimally invasive operations Ann Thorac Surg 1996;62:1158-1163.[Abstract/Free Full Text]
  23. Perrault LP, Menasche P, Bidouard JP. Snaring of the target vessel in less invasive bypass operations does not cause endothelial dysfunction Ann Thorac Surg 1997;63:751-755.[Abstract/Free Full Text]
  24. Demaria RG, Fortier S, Malo O, Carrier M, Perrault LP. Influence of intracoronary shunt size on coronary endothelial function during off-pump coronary artery bypass Heart Surg Forum 2003;6:160-168.[Medline]
  25. Dapunt OE, Raji MR, Jeschkeit S. Intracoronary shunt insertion prevents myocardial stunning in a juvenile porcine MIDCAB model absent of coronary artery disease Eur J Cardiothorac Surg 1999;15:173-178.[Abstract/Free Full Text]
  26. Lucchetti V, Capasso F, Caputo M, Grimaldi G, et al. Intracoronary shunt prevents left ventricular function impairment during beating heart coronary revascularization Eur J Cardiothorac Surg 1999;15:255-259.[Abstract/Free Full Text]
  27. Menon AK, Albes JM, Oberhoff M, Karsch KR, Ziemer G. Occlusion versus shunting during MIDCAB: effects on left ventricular function and quality of anastomosis Ann Thorac Surg 2002;73:1418-1423.[Abstract/Free Full Text]
  28. Yeatman M, Caputo M, Narayan P, et al. Intracoronary shunts reduce transient intraoperative myocardial dysfunction during off-pump coronary operations Ann Thorac Surg 2002;73:1411-1417.[Abstract/Free Full Text]
  29. Feuchtner GM. Non-invasive imaging of vein grafts with multislice computed tomography Eur Surg 2007;39:105-110.
  30. Ross R, Gloset JA. Atherosclerosis and arterial smooth muscle cell Science 1973;180:1332-1339.[Free Full Text]
  31. Vanhoutte PM, Perrault LP, Vilaine JP. Endothelial dysfunction and vascular diseaseIn: Rubanyi GM, Dzau VJ, editors. The endothelium in clinical practice. New York, NY: Marcel Decker; 1997. pp. 265-289.
  32. Cheng G, Loree H, Kamm R, Fishbein M, Lee R. Distribution of circumferential stress in ruptured and stable atherosclerotic lesions. A structural analysis with histopathological correlation. Circulation 1993;87:1179-1187.[Abstract/Free Full Text]
  33. Gerola LR, Moura LA, Leao LE, Soares HC, Branco JN, Buffolo E. Arterial wall damage caused by snaring of the coronary arteries during off-pump revascularization Heart Surg Forum 2000;3:103-106.[Medline]
  34. Izutani H, Gill I. Acute graft failure, caused by an intracoronary shunt in minimally invasive direct coronary artery bypass grafting J Thorac Cardiovasc Surg 2003;125:723-724.[Free Full Text]



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