Asian Cardiovasc Thorac Ann 2006;14:72-74
© 2006 Asia Publishing EXchange Ltd
New Anastomosis Assist Devices for Coronary Artery Bypass Grafting
Yoshiei Shimamura, MD,
Takahiro Takemura, MD,
Kouta Agematsu, MD
Department of Cardiovascular Surgery, National Nagano Hospital, Nagano, Japan
For reprint information contact: Yoshiei Shimamura, MD, Tel: 81 282 861 111, Fax: 81 282 864 775, Email: simamura{at}dokkyomed.ac.jp, Department of Thoracic and Cardiovascular Surgery, Dokkyo University School of Medicine, 880, Kitakobayashi, Mibumachi, Shimotsugagunn, Tochigi 321-0293, Japan.
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ABSTRACT
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Two new graft holders and an anastomosis assist mirror, designed for coronary artery bypass grafting, are described. The graft holders are pinching devices with sponges inside to prevent graft injury. The anastomosis assist mirror is a small circular mirror designed to show a reflective view of the lateral or posterior wall of the heart. Together they can provide secure stabilization of the graft and an excellent view of the anastomotic site.
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INTRODUCTION
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Pickup forceps or various graft holders are commonly used to hold the graft during coronary artery bypass grafting (CABG).1–3 These devices have some problems, however, such as graft injury or an insufficient grip on the graft, while requiring direct manipulation on the heart to expose and immobilize the lateral or posterior wall of the heart. This may cause hemodynamic instability during off-pump CABG.4 We introduce three new types of anastomosis assist devices which can resolve these problems.
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MATERIALS AND METHODS
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1. End graft holder (Figure 1-A, a
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This graft holder is a pinching device that is modified from the marketed paper clip with a multi-jointed, flexible arm and a fixation clamp. The pinching device forms a convex, curved shaped clip (15 mm in width, 32 mm in length and 6 mm between the blades of the clip). Two pieces of sponge are fitted inside each of the two blades. The graft end is trimmed, then it is put between sponges and indirectly pinched by the clip (Figure 2-A). The fixation clamp is placed at an edge of a sternal retractor. Nonskid, rubber seats are fitted inside the clamp to prevent the holder from slipping off the retractor. By bending and changing the shape of the arm of the holder, the open end of the graft is positioned to the required specification. Anastomosis is started at the heel using a loose continuous suture technique. After the heel side anastomosis is completed, the graft is released from the holder and put together by pulling two ends of the suture. The remaining anastomosis is then completed. The device can also be used in proximal anastomosis on the aorta or in making a composite graft. Moreover, the device is useful as a holder of pencil type graft holders or as a humidified carbon dioxide blower.
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Figure 1. The anastomosis assist devices (top with capital letters) and the heads of them (bottom with small letters). (A, a) The end graft holder; (B, b) the side graft holder; (C, c) the anastomosis assist mirror.
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Figure 2. Intraoperative schemata of the devices. (A) The end graft holder holds the open end of the graft securely and gently. (B) The side graft holder straddles on and exposes the side opening of the graft finely and firmly. (C) The anastomosis assist mirror presents an excellent reflective view of the anastomotic site.
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2. Side graft holder (Figure 1-B, b
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This graft holder is used in end-to-side anastomosis of T-shaped composite grafts. It also has a convex shaped clip, which is wider than the former end graft holder (40 mm in width). One of the blades of this clip has a U-shaped, rectangular opening (30 x 15 mm). Two pieces of trimmed sponge are affixed inside the two blades. The U-shaped blade straddles and exposes the graft to facilitate a side opening and the graft is held by the clip gently in two points (Figure 2-B). After the graft is incised and the side opening is made, anastomosis is started at the heel in a loose continuous manner. The other graft, which has an end opening, is approximated on the way, and the remaining suture is completed.
3. Anastomosis Assist Mirror (Figure 1-C, c)
An anastomosis assist mirror is a small circular mirror (30 mm in diameter) which also accompanies a flexible arm and a clamp. It is designed to offer a view of the circumflex coronary artery which is often troublesome to access from the median sternotomy incision. After the device is fixed on the sternal retractor with the clamp, the mirror is positioned beside the target coronary artery by regulating the multiple joints of the flexible arm. The mirror provides an excellent view of the target coronary artery reflectively and indirectly without excessive force on the heart (Figure 2-C).
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DISCUSSION
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Secure stabilization and good visualization of the graft, along with those of the target coronary artery, are the keys to successful off-pump CABG. Various graft holders have been designed to facilitate CABG,1–3 but they have shown problems such as incomplete stabilization of the graft, inappropriate grasping power, size mismatch to the graft or graft intimal injury. In addition, it is difficult and troublesome to anastomose two grafts because the fixation of each graft is often incomplete and unstable in the narrow pericardial space.
The new graft holders are simple, inexpensive, and disposable pinching devices. Regardless of the size or the kind of the graft, or the amount of surrounding tissue, the graft can be fixed gently due to the softness of the sponge. There is no danger of crush injury even to a delicate intra-mammary artery graft without a pedicle. The graft does not twist during placement in the holder due to the friction between the sponge and the graft. The clips are designed for easy attachment and release. The graft can be positioned to any specification due to the flexible arm. The length and the shape of the arm are flexible by design. Situations requiring surgical assist staff can potentially be reduced. These graft holders offer an excellent view of the opening of the graft, which enables precise stitch placement, and minimal handling and anastomosis time.
In order to view the invisible coronary arteries of the posterior or lateral wall of the beating heart, direct manipulation on the heart is critical from the sternotomy approach. This can produce hemodynamic instability, which may subsequently require unnecessary inotropic drugs, volume overload or mechanical cardiac assistance.4–5 Even when using a well designed heart positioner or stabilizer, the target coronary artery is seen in a perpendicular position. During anastomosis in this position, it is difficult to confirm the biting width of the heel part, the sewing width of the side part or the intimal biting of the toe part of the coronary artery. The anastomosis assist mirror is a simple device, but helpful, like the rearview mirror of a car. By diminishing excessive manipulation on the heart, this device may reduce hemodynamic instability and unnecessary cardiac assistance during off-pump CABG.
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REFERENCES
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