Asian Cardiovasc Thorac Ann 2007;15:74-75
© 2007 Asia Publishing EXchange Ltd
Novel Technique for Proximal Anastomosis of Vein Graft to Right Coronary Artery
Jayapadman Bhaskar, FRCS,
Ashok K Sharma, FRACS
Department of Cardiothoracic Surgery, Wellington Public Hospital, Wellington South, New Zealand
For reprint information contact: Ashok K Sharma, FRACS Tel: 64 4 385 5999 Fax: 64 4 385 5538 Email: ashok.sharma{at}ccdhb.org.nz, Wellington Public Hospital, Private Bag 7902, Wellington South, New Zealand.
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ABSTRACT
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A novel technique for anastomosis of the proximal (aortic) end of the saphenous vein conduit to the right coronary territory is described. This has proved to be an excellent technique that can be performed expeditiously with minimal assistance. It is easily reproducible with consistent results, even for surgeons in the initial stages of their learning curves.
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INTRODUCTION
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Grafting a venous conduit to the aorta, to bypass the right coronary or posterior descending coronary artery, is considered to be more technically challenging than proximal anastomosis of the left coronary arteries. This is because the top ends have to be held by an assistant in such a way as to make them accessible for a right-handed surgeon. This could make it difficult and cumbersome for an inexperienced surgeon, especially while placing the heel sutures. A novel technique that has been used by the senior author for the last 25 years, is described.
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TECHNIQUE
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The proximal anastomosis, performed with a single application of a side-biting clamp, is preceded by the distal anastomosis. The length of the vein graft is assessed, and the vein is divided at the aortic end in an oblique manner. A 5/0 Prolene suture is passed through the tip of the toe end of the venous conduit, and used to anchor the vein to the pericardial edge on the right side. The aortotomy is undertaken in a standard fashion, using a 4.6 mm punch, and the anastomosis is started. A 6/0 Prolene suture is used in a forehand manner and taken out through the vein at the toe end, and a clip is applied to it (Figure 1
). The other end of the suture is used to start the anastomosis, taking it out of the aorta at the cranial end and into the vein, and following downwards towards the heel. The assistant follows the suture so as to keep it retracted towards the cranial end, as the surgeon proceeds towards the heel. With each stitch taken along with the vein, the aortotomy also opens up and this makes it very expeditious (Figure 2). Once the heel is reached, the anchoring suture is divided and the vein is parachuted down (Figure 3). The suturing is continued on the other side caudocranially in a forehand manner until the toe end is reached, where the suture is tied down.
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Figure 1. (A) Photograph and (B) diagram showing the proximal end of the vein graft anchored to the right pericardial edge. SVC = superior vena cava, RA = right atrial.
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Figure 2. (A) Photograph and (B) diagram highlighting the opening up of the free edge of the vein as well as the aorta as the anastomosis proceeds.
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Figure 3. The vein, after it has been detached from the pericardial edge, is brought down after suturing one side to the aortotomy.
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DISCUSSION
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Coronary artery surgery has come a long way since the days of Favaloro1 who advocated a triangular opening in the ascending aorta and 5/0 interrupted silk sutures for construction of a proximal anastomosis. Cooley2 maintained that special cutting devices (aortic punches) were unsatisfactory. Nowadays, the top ends are conventionally handled with a side-biting clamp when performed by either the on-pump or off-pump techniques, although some surgeons would advocate using a crossclamp. After selecting the site of anastomosis and preparing the aorta, an aortotomy is made with a size 11 blade knife, and expanded using a punch. An assistant traditionally holds the vein with either a pair of forceps or a vein holder, and the surgeon starts the anastomosis from the heel end. This step may be quite difficult for a right-handed surgeon doing a right-sided anastomosis, in contrast to proximal anastomoses to the circumflex territory. This is essentially because the bevelled top end does not face the surgeon but tends to face cranially. This demands more dexterity on the part of the surgeon, especially those at the lower end of their learning curves.
The technique described herein has several advantages. With each bite taken, the vein and the aortotomy open up, thus facilitating a rapid procedure. It can be carried out at reasonable speed (within 6–7 min). This reduces the crossclamp time and/or pump time, with obvious advantages. The lie of the graft is good with a smooth and gentle curve, without any kink of the graft or tension on the anastomosis. There is minimal vein handling with this technique, and it can be performed with minimal assistance.
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REFERENCES
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- Favaloro RG. Saphenous vein graft in the surgical treatment of coronary artery disease. Operative technique. J Thorac Cardiovasc Surg 1969;58:178–85.[Medline]
- Cooley DA. Revascularization of the ischemic myocardium. J Thorac Cardiovasc Surg 1979;78:301–4.[Medline]
TOP
ABSTRACT
INTRODUCTION
