Ann Thorac Surg 2009;87:1628-1629. doi:10.1016/j.athoracsur.2008.09.034
© 2009 The Society of Thoracic Surgeons
How To Do It
A Novel Side Graft Holder for Coronary Artery Bypass Grafting
Yoshiei Shimamura, MD*,
Ichiro Hayashi, MD
Department of Cardiovascular Surgery, Saitama City Hospital, Saitama, Japan
Accepted for publication September 11, 2008.
* Address correspondence to Dr Shimamura, Department of Cardiovascular Surgery, Saitama City Hospital, 2460 Mimuro, Midoriku, Saitama City, Saitama, 336-8522, Japan (Email: shimasantamerry{at}tulip.ocn.ne.jp).
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Abstract
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We describe the construction and use of a novel side graft holder for coronary artery bypass grafting. The device is a hammer head-shaped clip used to hold the graft side securely but atraumatically during sequential or composite graft anastomosis. The side graft holder provides gentle stabilization and excellent visualization of the side of the graft without causing graft injury.
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Introduction
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Sequential bypass and composite graft anastomosis techniques have been widely used with increasing frequency in coronary artery bypass grafting for multivessel coronary artery disease or severe atheromatous ascending aorta [1, 2]. These techniques have several advantages including conservation of bypass graft vessels and reduction in the number of proximal aortic anastomoses required; practically, however, the technique is difficult to accomplish. The grafts are unstable in the tight pericardial space and are prone to slipping away from the tip of the suture needle. Graft instability can annoy the surgeon, extend anastomosis time, and influence anastomotic patency. Various devices or methods have been described to stabilize and position the distal end of the graft during end-to-side anastomosis during coronary artery bypass grafting [3, 4], but few methods have been advanced for stabilization of the side of the graft during side-to-side anastomosis [5]. Moreover, these devices have several drawbacks, including inadequate grasping of the graft, incomplete graft stabilization, or causing intimal injury to the graft. We describe a technique for side-to-side graft anastomosis with a novel side graft holder that improves on these technical limitations.
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Technique
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In cooperation with Merzen Products Inc (Aichi, Japan), we have developed a new side graft holder that consists of a hammer head-shaped clip (30-mm wide, 10-mm deep, and 6-mm thick) attached to a flexible arm and fixation clamp (Fig 1A). One of the blades of the clip has a U-shaped, rectangular opening (20 mm x 10 mm), and two pieces of trimmed sponge are affixed to the inside edge of each U-shaped blade (Fig 1B). The arm of the holder is flexible, multi-jointed, and is 10 mm in diameter. The fixation clamp is designed to attach to the sternal retractor. A small rectangular plate is connected to the inside of one of the clamp blades with a hinge joint, which allows firm fixation of the clamp to a retractor of 3 to 12 mm in thickness (Fig 1C).
As the first step of sequential or composite graft anastomosis with the device, the fixation clamp is attached to the sternal retractor (Fig 2A). The graft is trimmed and prepared for the anastomosis, and then the graft is pinched by the clip at two points so that the U-shaped blade of the clip straddles the anastomosis site and exposes the side of the graft (Fig 2B). A longitudinal incision is made into the graft between the two edges of the U-shaped blade. By bending and changing the shape of the arm, the clip is positioned to place the opening in the side of the graft adjacent to the coronary artery incision. When creating the diamond-shaped side-to-side anastomosis, the incisions are positioned to meet at right angles (Fig 2C). Anastomosis is begun at the distal side of the coronary arteriotomy. Loose running suture is then continued between the graft and the coronary arteriotomy (Fig 2D). After the distal-side anastomosis is complete, the graft is released from the holder and approximated to the coronary artery by pulling on the two ends of the suture (Fig 2E). The remaining proximal-side anastomosis is then completed (Fig 2F). When making the end-to-side anastomosis of a T-shaped composite graft, the device can be used in the same fashion. In this situation, the anastomosis can be completed without releasing the graft from the device.
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Fig 2. Schematic illustration of side-to-side graft anastomosis using the side graft holder. (A) The fixation clamp of the device is attached to the sternal retractor. (B) The graft is pinched, and the side of the graft is exposed by the clip. (C) Incisions are made into the side of the graft and the target coronary artery. (D) The graft and the coronary artery are anastomosed with a loose continuous suture technique. (E) The graft is released from the clip and approximated to the coronary artery. (F) The remaining side graft anastomosis is completed.
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We initially applied the side graft holder in 27 patients who underwent coronary artery bypass grafting surgery. The device was used for 40 anastomoses (sequential venous anastomoses, 37; composite arterial anastomoses, 3). No structural problems or graft injury occurred during use of the device. Postoperative angiography showed that all sequential and composite graft anastomoses were patent and without stenosis.
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Comment
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There are several advantages to this new side graft holder. It is a simple pinching device with a sponge lining that produces good atraumatic fixation of the side of the graft regardless of graft size or type or the amount of surrounding tissue present. Its use reduces both direct manipulations by hard instruments and intimal injury to the graft. The clip is designed for rapid attachment and release, and the device can be positioned as desired with the flexible arm. The device reduces the need for ancillary assistance and frees an assistant to perform other tasks, such as using a CO2-blower/mister or dealing with the suture threads. Finally, the opening on the side of the graft can be clearly visualized and stabilized near the target coronary artery to allow precise graft positioning and suturing with minimal handling and anastomosis time.
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References
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- Christenson JT, Schmuziger M. Sequential venous bypass grafts: results 10 years later Ann Thorac Surg 1997;63:371-376.[Abstract/Free Full Text]
- Kobayashi J, Sasako Y, Bando K, et al. Multiple off-pump coronary revascularization with "aorta no-touch" technique using composite and sequential methods Heart Surg Forum 2002;5:114-118.[Medline]
- Mobin-Uddin K, Pleasant R. Vascular anastomosis with Mobin-Uddin vein/graft holder Ann Thorac Surg 1986;42:591-592.[Abstract/Free Full Text]
- Suma H, Takeuchi A. Vein holder for coronary bypass surgery Ann Thorac Surg 1987;43:109-110.[Abstract/Free Full Text]
- Kawasuji M, Sakakibara N, Watanabe Y, Kitamura A. A new vein holder for side-to-side saphenous-coronary anastomosis Kyobu Geka 1992;45:225-226.[Medline]
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939 - 942.
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Abstract
Introduction
