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Original Articles: Adult Cardiac

Invited Commentary

The Interventional Centre, Rikshospitalet, 0027 Oslo, Norway

(Email: nielsb{at}aol.com).

A benefit of off-pump coronary artery bypass (OPCAB) surgery is reduced need for manipulation of the aorta. However, most OPCAB surgeries are still performed with partial clamping of the aorta and handsewn proximal anastomosis. The development of connectors for fastening vein grafts to the aorta without clamping was met with excitement by cardiac surgeons. St. Jude Symmetry connectors (St. Jude, Inc, St. Paul, MN) were used extensively after a promising introduction, but controlled angiographic studies demonstrated an unacceptable occlusion rate [1].

The Leipzig group has conducted a randomized study of patency of grafts performed with PAS-port proximal connectors (Cardica Inc, Menlo Park, CA) compared with hand-sewn proximal anastomosis. Kempfert and colleagues [2] demonstrates that if used properly, the PAS-port may make OPCAB surgeries easier and faster, and may possibly reduce the rate of complications. Patency rates of vein grafts in both treatment groups are exceptional and higher than in most other studies. This may be due to selection of cases, use of sequential anastomosis, routine postoperative administration of clopidogrel and aspirin or exceptional surgical skills. However, the fact that the PAS-port constructed grafts had better patency than proximal anastomosis that were handsewn is important, which is in stark contrast with what was found in the Symmetry studies. This may be due to any of the previously mentioned factors or inherent to the device itself. The PAS-port has no ring-like structure at the inlet and less exposed metal than the Symmetry. Potential damage to the intima is reduced because there is less instrumentation of the vein.

Based on this study from Leipzig, it seems reasonable to use the PAS-port for proximal anastomosis, at least in selected cases. Surgeons who wish to use the device should pay strict attention to details, especially to prevent kinking and obtain optimal graft length. The excellent patencies demonstrated in this study, raises the question of whether clopidogrel should be given routinely after all OPCAB procedures using the saphenous vein, even when connectors are not used.

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1. Bergsland J, et al. Intraoperative and intermediate-term angiographic results of coronary artery bypass surgery with Symmetry proximal anastomotic device J Thorac Cardiovasc Surg 2004;128:718-723.[Abstract/Free Full Text]
2. Kempfert J, Opfermann UT, Richter M, Bossert T, Mohr FW, Gummert JF. Twelve-month patency with the PAS-port proximal connector device: a single center prospective randomized trial Ann Thorac Surg 2008;85:1579-1585.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jacob Bergsland Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bergsland, J. Search for Related Content PubMed PubMed Citation Articles by Bergsland, J. Related Collections Coronary disease Related Article