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Ann Thorac Surg 1999;68:246-248
© 1999 The Society of Thoracic Surgeons

Case Reports

Septal branch right ventricular fistula: a complication in coronary artery snaring

Kazuo Tanemoto, MDa, Keiichiro Kuroki, MDa, Yuji Kanaoka, MDa, Takashi Murakami, MDa

a Department of Cardiovascular Surgery, Iwakuni National Hospital, Iwakuni, Japan

Address reprint requests to Dr Tanemoto, Department of Cardiovascular Surgery, Iwakuni National Hospital, Iwakuni, 740-8510, Japan
e-mail: kaztane{at}enjoy.ne.jp


   Abstract
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We report a septal branch right ventricular fistula complicated after coronary snaring in coronary artery bypass surgery without aortic cross-clamping. The tip of the needle of the snaring suture is made blunt in order to decrease the risk of mechanical injury, but trauma to the septal branch is possible. This rare complication of snaring should be taken into consideration in performing aortic nonclamping coronary artery bypass surgery.


   Introduction
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Coronary artery bypass surgery without aortic cross-clamping, such as minimally invasive direct coronary artery bypass (MIDCAB), off-pump bypass, and on-pump beating heart bypass, have been widely accepted for many reasons [1, 2]. In these operations, it is necessary to stop the coronary artery blood flow temporarily to make the anastomotic field bloodless. Coronary artery snaring with thread has been employed for this purpose [1, 2]. We report a rare complication of septal branch right ventricular fistula after aortic nonclamping coronary artery bypass surgery.

A 71-year-old man with two-vessel coronary disease was scheduled to undergo coronary artery bypass surgery. The preoperative computed tomography revealed a severely calcified aortic wall at the ascending aorta. Conventional coronary artery bypass surgery with aortic cross-clamping was considered to be to dangerous because of the risk of embolism from the calcified aortic wall. Two-vessel coronary artery bypass grafting, under cardiopulmonary bypass without aortic cross-clamping, was planned. Via a median sternotomy, the left internal thoracic artery was anastomosed to the left anterior descending coronary artery (LAD), and the right gastroepiploic artery to the left circumflex coronary artery. To make the anastomotic field bloodless, a snare was used proximal and distal to the anastomotic site. The snare was an elastic thread with a 23-mm, half-circle, blunt needle (Matsuda, Tokyo, Japan). After the anastomoses were performed in the usual manner, the elastic thread was removed. A small amount of bleeding was observed from the epicardium where the elastic thread had been passed. Hemostasis was obtained with simple digital compression. The postoperative course was uneventful. The postoperative angiography, performed on the 17th postoperative day, revealed a septal branch right ventricular fistula (Fig 1), which was not observed in the preoperative coronary angiography (Fig 2). The patient is doing well postoperatively, and shows no evidence of myocardial ischemia or congestive heart failure.



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  		Fig 1. Postoperative angiography of left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD). Septal branch right ventricular fistula can be observed at the site where the snaring suture passed through the myocardium.

 


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  		Fig 2. Preoperative coronary angiography. No coronary right ventricular fistula was found.

 

   Comment
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In aortic nonclamping coronary artery bypass surgery, such as a MIDCAB, off-pump bypass, or on-pump on-beating bypass, keeping the operative field dry is mandatory in performing anastomosis to the targeted coronary artery. An encircling snare suture with elastic thread is a widely employed method for this purpose [1, 2]. The needle of the snaring suture should have a blunt tip in order to avoid injuring the coronary artery. It is currently recommended that the snare be passed some distance from the targeted coronary artery in order to minimize the risk of damage to that artery. Thus, the snaring suture may pass through the right ventricular cavity. In our special case, the blunt tip of the needle accidentally penetrated the septal branch and then passed through the right ventricular cavity. Subsequently, a septal branch right ventricular fistula, which did not close after removing the snaring thread, developed. Since this fistula had a very small shunting volume, it should present no hemodynamic problems for the patient.

It has been reported that snaring the coronary artery for achieving hemostasis at the anastomotic site does not cause endothelial dysfunction [3]. But there is some possibility of mechanical trauma, especially in diseased coronary arteries, as well as the possibility of trauma secondary to the blunt needle [4]. The tip of the needle is made blunt in order to decrease the risk of mechanical injury, but it does not eliminate that risk entirely. Since it is very difficult to determine the origin of the septal branch, trauma to this vessel is possible. This rare complication of snaring should be taken into consideration in performing aortic nonclamping coronary artery bypass surgery.

Another method for keeping the operative field dry consists of using a humidifying blower and clamping the coronary artery with an atraumatic bulldog clamp. It is frequently difficult to keep the operative field dry only by using a humidifying blower because of the coronary blood flow from the proximal vessel. Moreover, for clamping the LAD, dissection around the coronary artery is required, and this procedure can possibly lead to more blood loss. We now routinely use the snaring suture only at the site proximal to the anastomosis, and control the back flow from the distal vessel with simple compression by means of a stabilizer.


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  1. Benetti F.J., Naselli G., Wood M., Geffner L. Direct myocardial revascularization without extracorporeal circulation. Chest 1991;100:312-316.[Abstract/Free Full Text]
  2. Buffolo E., Andrade J.C.S., Brabco J.N.R., Aguiar L.F., Ribeiro E.E., Jatene A.D. Myocardial revascularization without extracorporeal circulation. J Cardiothorac Surg 1990;4:504-508.
  3. Perrault L.P., Menasché P., Bidouard J.P., et al. 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]
  4. Alessandrini F., Gaudino M., Glieca F., et al. Lesions of the target vessel during minimally invasive myocardial revascularization. Ann Thorac Surg 1997;64:1349-1353.[Abstract/Free Full Text]
Accepted for publication December 24, 1998.


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This Article
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