Asian Cardiovasc Thorac Ann 2005;13:380-381
© 2005 Asia Publishing EXchange Ltd
Saphenous Vein Patch Plasty to Correct Saphenous Graft and Aortotomy Mismatch
Uday Dandekar, FRCS,
Maninder S Kalkat, FRCS,
Paul Ridley, FRCS
Department of Cardiothoracic Surgery, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
For reprint information contact: Maninder Singh Kalkat, FRCS Tel: 44 192 262 4653 Fax: 44 121 627 5736 Email: mankalkat{at}hotmail.com, 12 Redruth Close, Parkhall, Walsall WS5 3ER, United Kingdom.
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ABSTRACT
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Mismatch of aortotomy and saphenous vein graft size occasionally occurs and can compromise the contour of the anastomosis thereby jeopardising its patency. We describe an alternative technique of saphenous vein patch plasty to overcome this complication by giving a more desirable hooded contour to the anastomosis. This results in improved graft patency, hemostasis and clinical outcome.
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DISCUSSION
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An important determinant of early graft patency is the quality of the surgical technique.1 There are various surgical sites where an aortocoronary bypass graft with a saphenous vein can be compromised. These include the distal anastomosis where a twist in the vein graft and discrepancy in the length of vein may give rise to tension or kinking of the graft. The proximal anastomosis may also be compromised. One mechanism resulting in proximal anastomotic compromise is a mismatch in the aortotomy and saphenous vein graft size. This occurs when a standard punch hole is performed in the ascending aorta, however the vein conduit is of narrow calibre. This alters the anastomotic contour, flattens the vein and subsequently leads to compromised flow through the graft. Clinically, it is preferable to avoid a situation of aortotomy and saphenous vein mismatch, thereby reducing vein graft occlusion and resultant sequelae. Whilst a slit aortotomy without removal of any tissue from the aorta may be considered to avoid this problem, the situation is nevertheless occasionally encountered. Various surgical options have been proposed:
- Disconnect the vein graft from the aortotomy, close the aortotomy directly, refashion the vein graft and anastamose to a more appropriately sized aortotomy (typically a slit aortotomy). However, it is not always straightforward to close an aortotomy hemostatically.
- Disconnect the vein graft from the aortotomy, close the aortotomy and instead of re-anastomosing the vein to the aorta, it is anastamosed end to side to another vein graft that has been already joined to the aorta. A direct vein-to-vein anastomosis may potentially place both the grafts at risk of early occlusion.
- Insert a partial thickness stitch placed circumferentially around the aortotomy and tie it with sufficient tension without excessively narrowing the anastomosis.2 Too much tension on the stitch may cause anastomotic narrowing.
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METHOD
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An alternative technique is described. A side-biting clamp is applied around the aortotomy and the saphenous vein graft site. A bulldog clamp is applied around the midportion of the vein graft. A longitudinal venotomy is performed just over the hood of the proximal anastomosis. An appropriately sized diamond shaped patch of saphenous vein is fashioned and sutured to the venotomy forming a hooded contour using two 7/0 prolene double-ended double-armed sutures. The suture is commenced at the apex of the diamond on each side and tied on to the venotomy. Both these sutures are then run on either side and tied at the midpoint on each side avoiding any purse string effect (Figure 1
). De-airing is achieved via the venotomy site after removing the side biting clamp on the aorta and prior to tying the knots on the vein patch. This simple technique can eliminate the distortion caused by aortotomy and saphenous graft mismatch.
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Figure 1. The kinked and compromised proximal saphenous vein-aortic anastomosis (Above) and vein patch plasty to rectify it (Below).
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The described technique is only applicable in the event of saphenous vein-aortotomy mismatch. The size of a vein of small but acceptable calibre (3 mm – 5 mm in diameter) prevents a natural hooded contour being achieved at the proximal anastomotic site. Without a patch plasty, the proximal anastomotic site would be largely flattened, compromising patency and flow. Merely extending the venotomy will not eliminate the risk of flattening and will not give a natural hooded appearance to the proximal anastomosis.
It is difficult to demonstrate short and long-term results with a technique that may be applicable only on a rare occasion. The aim here is to demonstrate an alternative technique available in the surgeon’s armamentarium, which may be considered in a situation like the one described, and not claim its superiority over others.
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REFERENCES
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- Angelini GD. Saphenous vein graft failure: etiologic considerations and strategies for prevention. Curr Opin Cardiol 1992;7:939–44.[Medline]
- John LC. Mismatch of aortotomy and saphenous vein graft size: a simple solution. Ann Thorac Surg 1996;62:598–9.[Abstract/Free Full Text]
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ABSTRACT
DISCUSSION
