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Side-to-Side Anastomosis in Off-Pump Coronary Artery Bypass Grafting

Cardiac Disease Centre Yamato Seiwa Hospital Yamato City, Japan

For reprint information contact: Akihiro Nabuchi, MD Tel: 81 46 278 3911 Fax: 81 46 278 5787 email: nabuchi{at}seiwa.or.jp Department of Cardiac Surgery, Yamato Seiwa Hospital, 9-8-2 Minami Rinkan, Yamato City, Kanagawa 242-0006, Japan.

	Abstract

TOP Abstract Introduction Technique Discussion References

 
A technique is described for side-to-side anastomosis as a functional end-to-side anastomosis, in which no direct contact with the vessel walls by surgical instruments is required during suturing, thus avoiding the possibility of damage to the graft.

	Introduction

TOP Abstract Introduction Technique Discussion References

 
When performing off-pump coronary artery bypass grafting, small vibrations cannot be avoided when suturing the graft to the coronary artery, even when using a stabilizer. The fragility of the left internal mammary artery (LIMA), particularly in females, can be sometimes to the extent that any simple surgical maneuver such as suturing can exert sufficient shearing force to damage the graft. In routine grafting of LIMA to left anterior descending coronary artery (LAD) as a functional end-to-side anastomosis, the parallel side-to-side anastomosis technique is strongly recommended for off-pump grafting, especially when the patient is female.

	Technique

TOP Abstract Introduction Technique Discussion References

 
In the case of LAD revascularization, after adequate preparation of the anastomotic site on the LAD, a parallel incision (arteriotomy) is made for anastomosis. The incision in the LIMA is made 1 or 2 cm from the distal end of the pedicle on the anterior side where the surface of the LIMA wall is usually exposed directly, and the pedicle is positioned comfortably for anastomosis (Figure 1A). After 4 or 5 sutures have been placed around the heel part, the LIMA is brought into contact with the LAD via the parachute technique. The distal end of the pedicle including the LIMA is held and pulled upwards towards the surgeon, while the lateral parts of the anastomosis are sutured up to the toe part (Figure 1B). On completion of the sutures at the toe, the pedicle is pulled towards the apex of the heart to align the suture line between the LIMA and the LAD (Figure 1C). The distal end of the LIMA is closed by a clip 5 mm from the site of anastomosis.

View larger version (231K): [in this window] [in a new window]   Figure 1. (A) The distal part of the pedicle of the left internal mammary artery is fixed to the edge of the sternum at the left. Suturing is started around the heel part of the anastomosis orifice by the parachute technique. (B) The anastomosis orifice of the graft is placed close to the left anterior descending coronary artery, and the stitches in the lateral side are started by holding the pedicle towards the surgeon, which provides an excellent view of the lumen of each vessel without directly touching the graft. (C) After completion of the stitches at the toe, the pedicle is pulled towards the apex of the heart and the gap between the vessels becomes straight.

	Discussion

TOP Abstract Introduction Technique Discussion References

In the technique described here, an artifactual "vascular dead space" is produced at the distal end of the LIMA graft. Angiograms performed in the early postoperative stage often show a small area infiltrated by contrast medium at the distal part of the LIMA beyond the anas-tomosis (Figure 2), suggesting a dead space. This space tends to disappear naturally with time and a normal blood stream pattern is observed eventually. This technique also produces a 180-degree rotation of the LIMA pedicle because of direct contact of the anterior surface of the pedicle with the LAD. This situation has not produced any unfavorable results or complications so far in our experience of more than 500 cases using the same technique in conventional coronary artery bypass surgery. A similar approach is recommended for the circumflex branches.

View larger version (124K): [in this window] [in a new window]   Figure 2. Early postoperative angiogram of a 58-year-old female. A small trace of contrast medium can be seen in the distal part of the graft beyond the anastomosis, indicating a dead space.

	References

TOP Abstract Introduction Technique Discussion References

 

1. McBride LP, Barner HB. The internal thoracic artery as a sequential graft to the left anterior descending system. J Thorac Cardiovasc Surg 1983;86:703–6.[Abstract]

2. Barner HB. Techniques of myocardial revascularization. In: Edmunds LH, editor. Cardiac surgery in the adult. 1st ed. New York: McGraw-Hill, 1997:507–8.

This Article Abstract 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Akihiro Nabuchi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nabuchi, A. Articles by Kim, K.-i. Search for Related Content PubMed Articles by Nabuchi, A. Articles by Kim, K.-i.