How to Do It
Single Heartstring aortotomy for multiple off-pump venous bypass grafts
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 609–611 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314539952 aan.sagepub.com
Lars Niclauss, Se´bastien Colombier and Rene´ Preˆtre
Abstract Off-pump coronary bypass grafting may decrease the rate of stroke, due to minimal aortic manipulation. For venous grafts, clampless hemostasis when performing the proximal anastomosis can be achieved using the Heartstring device. We describe a technique using a single device to suture two veins to one aortotomy. This technique requires less space and could be advantageous in very short, small, and calcified aortas. In to our experience, this technique is rapid, simple, easy to reproduce, and cost-saving.
Keywords Anastomosis, surgical, aorta, thoracic, coronary artery bypass, off-pump, saphenous vein
Introduction Off-pump coronary bypass grafting (CABG) may reduce the rate of stroke, due to minimal or no aortic manipulation compared to on-pump CABG.1 Ideally, complete arterial revascularization eliminates aortic manipulation but is not always practicable. Free venous grafts as an alternative option require aortic opening for proximal anastomosis. To avoid aortic side-clamping, sealing systems have been developed, and positive experiences have been reported.2 Generally, one device (Heartstring) is used for each anastomosis. We present a new technique for suturing two venous grafts on a single aortotomy.
Technique After completing the distal anastomosis and repositioning the heart, the venous bypass grafts are trimmed to the correct length and incised on their ‘‘aortic’’ side. The length of the incision should correspond to the free margin of the vein (initial venous circumference before incision). Avoiding rotation, a U-stitch is positioned in each incision angle using two 5/0 polypropylene sutures (Figure 1A). The aortotomy is achieved with a 4.3 mm cutter and the seal system is inserted (Heartstring III Proximal Seal System; Maquet, Wayne, NJ, USA). The veins are sutured, opposing each other, with their incised margins covering each
half of the hemisphere of the aortic hole (Figure 1B). The angle between the 2 veins can be slightly modified from a strict 180 position to assume an appropriate course. The sutures are tied and the free margins of the veins are sutured together, taking care to let the string of the sealing umbrella get out of the suture line in the remaining free angle (Figure 2A). The Heartstring is cut and pulled out in the usual manner, and the final suture is tied (Figure 2B).
Discussion Our initial experience with this rapid and reproducible technique was favorable with uneventful early followup of 2 months after surgical revascularization in the first 10 patients. The equivalent opposite suturing technique of two veins on a single aortotomy has been used without any problems for many years for on-pump CABG in our institution. Differences in outcome of off-pump versus on-pump CABG remain debatable; nevertheless, large studies
Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland Corresponding author: Lars Niclauss, MD, Department of Cardiovascular Surgery, University Hospital of Lausanne, 46 rue du Bugnon, CH-1011 Lausanne, Switzerland. Email: [email protected]
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
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Asian Cardiovascular & Thoracic Annals 23(5)
Figure 1. (A) After correct rotation, veins are incised on their ‘‘aortic’’ surface. Two U-stitches, placed in the venous incision angles, are passed from inside out through the aorta. Care should be taken to obtain a harmonious outflow angle. (B) The venous bypass graft to the left coronary branches is sutured and tied down, covering the left hemisphere of the aortic hole with its incised margin. The venous graft to the right coronary artery is already sutured to half of the circumference of the remaining right hemisphere.
Figure 2. (A) The final suture line of the free margins of the veins: they are sutured together, taking care to let the string of the sealing umbrella get out in the remaining free angle. (B) The Heartstring is cut and pulled out in the usual manner, and the final suture is tied.
found reduced early neurological and hemorrhagic complications after off-pump surgery.1,3 New techniques in off-pump CABG should focus on further reduction of aortic manipulation to achieve clampless or non-aortic complete revascularization.4 This may decrease the risk of embolization and the consequent stroke rate.5 Proximal sealing systems make it possible to perform a clampless anastomosis using free grafts.6 Usually, each anastomosis (using multiple venous grafts) is performed with a separate device, and the manufacturer recommends maintaining a distance of 1.5 cm apart to ensure hemostasis. To further reduce aortic trauma, a single aortotomy for two venous grafts may be advantageous and require less space in cases of small and severely calcified aortas. One-time
introduction of the seal system will reduce blood loss. The described technique is definitely cost-saving: only one single-use device is needed. The analogous suturing technique for multiples grafts on one aortotomy in cases of on-pump CABG with aortic crossclamping and cardiac arrest, has been systematically used in our department, with many years of positive experience.7 Techniques of multiple graft anastomoses using the Heartstring device have been described.2 It has been suggested to perform a side-to-side anastomosis between one vein and the aorta (as a T-graft), completed by end-to-end anastomosis between the first and second venous bypasses. Suture visibility of vascular borders of the side-to-side anastomosis is
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
Niclauss et al.
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suboptimal, and after that, performing the circular endto-end anastomosis to finish the procedure is time-consuming. The proximal segment of the first vein will be exposed to an inverted blood flow and must be valveless.2 The second option, performing end-to-side anastomosis of the first graft to the aorta and subsequently suturing the second vein to the hood of the first one (with the seal in place), corresponds more to our technique.2 Two different suture lines must be secured and well orientated for a correct inflow angle, and nearly half of the border of the first anastomosis consists of a small venous rim which is reused for the second suture. According to our experience, the presented technique is rapid, simple, easy to reproduce and cost saving, suturing two venous bypass grafts on one single aortotomy, using one HeartstringÕ device during multiple offpump CABG. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Brewer R, Theurer PF, Cogan CM, Bell GF, Prager RL and Paone G. Morbidity but not mortality is decreased after off-pump coronary artery bypass surgery. Ann Thorac Surg 2014; 97: 831–836. 2. Medalion B, Meirson D, Hauptman E, Sasson L and Schachner A. Initial experience with the Heartstring proximal anastomotic system. J Thorac Cardiovasc Surg 2004; 128: 273–277. 3. Hornero F, Martı´ n E, Rodrı´ guez R, et al. Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study. Eur J Cardiothorac Surg 2013; 44: 725–731. 4. Head SJ, Bo¨rgermann J, Osnabrugge RL, et al. Coronary artery bypass grafting: Part 2—optimizing outcomes and future prospects. Eur Heart J 2013; 34: 2873–2886. 5. Edelman JJ, Yan TD, Bannon PG, Wilson MK and Vallely MP. Coronary artery bypass grafting with and without manipulation of the ascending aorta—a meta-analysis. Heart Lung Circ 2011; 20: 318–324. 6. Emmert MY, Gru¨nenfelder J, Scherman J, et al. HEARTSTRING enabled no-touch proximal anastomosis for off-pump coronary artery bypass grafting: current evidence and technique. Interact Cardiovasc Thorac Surg 2013; 17: 538–541. 7. Sadeghi H and Morin D. Single aortotomy for multiple aortocoronary saphenous vein bypass grafts. Ann Thorac Surg 1982; 34: 89–91.
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
Single Heartstring aortotomy for multiple off-pump venous bypass grafts
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 609–611 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314539952 aan.sagepub.com
Lars Niclauss, Se´bastien Colombier and Rene´ Preˆtre
Abstract Off-pump coronary bypass grafting may decrease the rate of stroke, due to minimal aortic manipulation. For venous grafts, clampless hemostasis when performing the proximal anastomosis can be achieved using the Heartstring device. We describe a technique using a single device to suture two veins to one aortotomy. This technique requires less space and could be advantageous in very short, small, and calcified aortas. In to our experience, this technique is rapid, simple, easy to reproduce, and cost-saving.
Keywords Anastomosis, surgical, aorta, thoracic, coronary artery bypass, off-pump, saphenous vein
Introduction Off-pump coronary bypass grafting (CABG) may reduce the rate of stroke, due to minimal or no aortic manipulation compared to on-pump CABG.1 Ideally, complete arterial revascularization eliminates aortic manipulation but is not always practicable. Free venous grafts as an alternative option require aortic opening for proximal anastomosis. To avoid aortic side-clamping, sealing systems have been developed, and positive experiences have been reported.2 Generally, one device (Heartstring) is used for each anastomosis. We present a new technique for suturing two venous grafts on a single aortotomy.
Technique After completing the distal anastomosis and repositioning the heart, the venous bypass grafts are trimmed to the correct length and incised on their ‘‘aortic’’ side. The length of the incision should correspond to the free margin of the vein (initial venous circumference before incision). Avoiding rotation, a U-stitch is positioned in each incision angle using two 5/0 polypropylene sutures (Figure 1A). The aortotomy is achieved with a 4.3 mm cutter and the seal system is inserted (Heartstring III Proximal Seal System; Maquet, Wayne, NJ, USA). The veins are sutured, opposing each other, with their incised margins covering each
half of the hemisphere of the aortic hole (Figure 1B). The angle between the 2 veins can be slightly modified from a strict 180 position to assume an appropriate course. The sutures are tied and the free margins of the veins are sutured together, taking care to let the string of the sealing umbrella get out of the suture line in the remaining free angle (Figure 2A). The Heartstring is cut and pulled out in the usual manner, and the final suture is tied (Figure 2B).
Discussion Our initial experience with this rapid and reproducible technique was favorable with uneventful early followup of 2 months after surgical revascularization in the first 10 patients. The equivalent opposite suturing technique of two veins on a single aortotomy has been used without any problems for many years for on-pump CABG in our institution. Differences in outcome of off-pump versus on-pump CABG remain debatable; nevertheless, large studies
Department of Cardiovascular Surgery, University Hospital of Lausanne, Lausanne, Switzerland Corresponding author: Lars Niclauss, MD, Department of Cardiovascular Surgery, University Hospital of Lausanne, 46 rue du Bugnon, CH-1011 Lausanne, Switzerland. Email: [email protected]
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
610
Asian Cardiovascular & Thoracic Annals 23(5)
Figure 1. (A) After correct rotation, veins are incised on their ‘‘aortic’’ surface. Two U-stitches, placed in the venous incision angles, are passed from inside out through the aorta. Care should be taken to obtain a harmonious outflow angle. (B) The venous bypass graft to the left coronary branches is sutured and tied down, covering the left hemisphere of the aortic hole with its incised margin. The venous graft to the right coronary artery is already sutured to half of the circumference of the remaining right hemisphere.
Figure 2. (A) The final suture line of the free margins of the veins: they are sutured together, taking care to let the string of the sealing umbrella get out in the remaining free angle. (B) The Heartstring is cut and pulled out in the usual manner, and the final suture is tied.
found reduced early neurological and hemorrhagic complications after off-pump surgery.1,3 New techniques in off-pump CABG should focus on further reduction of aortic manipulation to achieve clampless or non-aortic complete revascularization.4 This may decrease the risk of embolization and the consequent stroke rate.5 Proximal sealing systems make it possible to perform a clampless anastomosis using free grafts.6 Usually, each anastomosis (using multiple venous grafts) is performed with a separate device, and the manufacturer recommends maintaining a distance of 1.5 cm apart to ensure hemostasis. To further reduce aortic trauma, a single aortotomy for two venous grafts may be advantageous and require less space in cases of small and severely calcified aortas. One-time
introduction of the seal system will reduce blood loss. The described technique is definitely cost-saving: only one single-use device is needed. The analogous suturing technique for multiples grafts on one aortotomy in cases of on-pump CABG with aortic crossclamping and cardiac arrest, has been systematically used in our department, with many years of positive experience.7 Techniques of multiple graft anastomoses using the Heartstring device have been described.2 It has been suggested to perform a side-to-side anastomosis between one vein and the aorta (as a T-graft), completed by end-to-end anastomosis between the first and second venous bypasses. Suture visibility of vascular borders of the side-to-side anastomosis is
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
Niclauss et al.
611
suboptimal, and after that, performing the circular endto-end anastomosis to finish the procedure is time-consuming. The proximal segment of the first vein will be exposed to an inverted blood flow and must be valveless.2 The second option, performing end-to-side anastomosis of the first graft to the aorta and subsequently suturing the second vein to the hood of the first one (with the seal in place), corresponds more to our technique.2 Two different suture lines must be secured and well orientated for a correct inflow angle, and nearly half of the border of the first anastomosis consists of a small venous rim which is reused for the second suture. According to our experience, the presented technique is rapid, simple, easy to reproduce and cost saving, suturing two venous bypass grafts on one single aortotomy, using one HeartstringÕ device during multiple offpump CABG. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Brewer R, Theurer PF, Cogan CM, Bell GF, Prager RL and Paone G. Morbidity but not mortality is decreased after off-pump coronary artery bypass surgery. Ann Thorac Surg 2014; 97: 831–836. 2. Medalion B, Meirson D, Hauptman E, Sasson L and Schachner A. Initial experience with the Heartstring proximal anastomotic system. J Thorac Cardiovasc Surg 2004; 128: 273–277. 3. Hornero F, Martı´ n E, Rodrı´ guez R, et al. Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study. Eur J Cardiothorac Surg 2013; 44: 725–731. 4. Head SJ, Bo¨rgermann J, Osnabrugge RL, et al. Coronary artery bypass grafting: Part 2—optimizing outcomes and future prospects. Eur Heart J 2013; 34: 2873–2886. 5. Edelman JJ, Yan TD, Bannon PG, Wilson MK and Vallely MP. Coronary artery bypass grafting with and without manipulation of the ascending aorta—a meta-analysis. Heart Lung Circ 2011; 20: 318–324. 6. Emmert MY, Gru¨nenfelder J, Scherman J, et al. HEARTSTRING enabled no-touch proximal anastomosis for off-pump coronary artery bypass grafting: current evidence and technique. Interact Cardiovasc Thorac Surg 2013; 17: 538–541. 7. Sadeghi H and Morin D. Single aortotomy for multiple aortocoronary saphenous vein bypass grafts. Ann Thorac Surg 1982; 34: 89–91.
Downloaded from aan.sagepub.com at UNIVERSITE LAVAL on November 15, 2015
