Interact CardioVasc Thorac Surg 2008;7:670-672. doi:10.1510/icvts.2008.179218
© 2008 European Association of Cardio-Thoracic Surgery
Follow-up papers - Cardiac general |
Successful six-year follow-up of a sutureless device for proximal anastomoses in a severely calcified ascending aorta
Thomas Puehlera,*,
Sandra Fraund-Cremerb,
Jochen Cremerb and
Andreas Boeningc
a Department of Cardiothoracic Surgery, University Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
b Department of Cardiovascular Surgery, University Schleswig-Holstein Campus Kiel, Arnold-Heller-Strasse 7, D-24105 Kiel, Germany
c Department of Cardiovascular Surgery, University Giessen, Rudolf-Buchheim-Str. 7, D-35392 Giessen, Germany
Received 5 March 2008;
received in revised form 30 April 2008;
accepted 6 May 2008
*Corresponding author. Tel.: +49-9419449824; fax: +49-9419449811.
E-mail address: thomas.puehler{at}klinik.uni-regensburg.de (T. Puehler).
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Abstract
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Background: Aortic connector devices (ACDs) for proximal anastomoses of vein grafts during coronary artery bypass grafting (CABG) have widely failed during recent years. As a consequence ACDs have been withdrawn from the market. Method: We report on an 81-year-old patient who had undergone CABG for three-vessel disease. The proximal anastomosis was accomplished with an ACD (St Jude Medical) due to a highly calcified ascending aorta. Six years later the patient underwent aortic valve replacement, which offered the opportunity of visual inspection of the previous ACD anastomosis. Result: Coronary angiography demonstrated a perfectly patent ACD anastomosis with a sufficient sequential vein graft to the marginal and the postero-lateral branches. Intraoperatively, the nitinol stent of the ACD anastomosis was perfectly incorporated, and covered with a thin layer of endothelial cells. Discussion: Though poor, short- and mid-term results have led to the abandonment of ACDs, our case demonstrates a perfect anastomosis after a six-year follow-up.
Key Words: Coronary artery bypass grafting (CABG); Vein graft; Anastomostic device
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1. Background
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Aortic (side-) clamping for generation of a proximal coronary artery bypass anastomosis is burdened with the risk of cerebral and systemic embolism of atherosclerotic debris. Off-pump surgery evolved as a new concept with complete arterial revascularization and avoidance of aortic manipulation. However, a substantial number of patients still need so-called proximal anastomoses. Apart from an aortic no touch technique, for these patients, aortic connector devices (ACDs) have been developed, to reduce the risk of atherosclerotic embolism, especially with regard to consecutive neurological disorders [1]. The SJM Bypass ACD was an easy to handle device, which allowed quick creation of reliable, reproducible, and uniform anastomoses. Mid-term follow-up data demonstrated no neuro-psychological benefit, but showed a high number of occluded vein grafts, which finally led to withdrawal of the device from the international market [2, 3]. We report on a patient with a 6-year follow-up and a still patent Symmetry device anastomosis.
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2. Method
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The 81-year-old male patient with a highly calcified aorta ascendens (Fig. 1) was admitted for coronary artery bypass grafting. During his first coronary bypass operation (18 November 2000), both internal mammaria arteries (IMA) and a sequential saphenous vein graft to the marginal and the postero-lateral branches had been used. After the approval of the local Institutional Review Board and obtaining informed consent, the operation was accomplished as a beating heart procedure, and the aortic anastomosis of the saphenous vein was performed utilizing the SJM Sutureless Symmetry ACD. The patient's postoperative course was uneventful. Within the following six years the maximum systolic aortic valve pressure gradient increased to 110 mmHg and the patient was referred for aortic valve replacement, which offered us the opportunity for re-catheterization and of visual inspection of the previous ACD anastomosis.
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3. Result
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Preoperative coronary angiography demonstrated patent IMA grafts, and a patent Symmetry ACD dependent sequential vein graft to the marginal and postero-lateral branches (Fig. 2). During redo surgery a biological valve prosthesis was implanted, avoiding injuries to the pre-existing patent bypass grafts. After aortotomy, the proximal saphenous vein graft could be inspected from the aortic lumen. The ACD was perfectly incorporated, i.e. a thin layer of endothelial tissue covered the metal parts of the device (Fig. 3). Surgery was well tolerated and the patient could be discharged 10 days later.
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4. Discussion
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In the literature, short-term patency rates of the ACDs created anastomoses did not differ from hand sutured vein grafts, but intermediate term patency (3–5 months) of ACD anastomoses has been poor. As a consequence, the routine use of the device has been abandoned [4, 5]. Kushagra et al. described an occlusion rate of 11% after a three-month follow-up with the SJM Symmetry ACD in 132 patients [6]. The underlying causes for graft failure seemed to be multi-facetted. Donsky et al. described two cases of acute thrombotic occlusion of the aortic anastomoses after using the SJM ACD. They hypothesized, that this complication may have a similar pathophysiological aspect to that seen in acute stent thrombosis and recommended an intensified use of anti-platelet therapy to prevent this complication [7]. Another reason for graft failure rates with the use of ACDs might be the arrangement of the proximal anastomosis and also the length of the graft. If the saphenous vein is inserted at the same point of the greater curvature of the ascending aorta as with hand-sewn anastomoses, the position of the vein graft is totally different. Without proper alignment of the vein graft there is an increased risk of kinking, leading to graft stenosis or occlusion [8]. Long-term patency is limited because of a combination of intimal hyperplasia and accelerated atherosclerosis. Up to 15% of vein grafts are occluded within one year, and more than 50% of vein grafts demonstrate significant degeneration within 10 years [9]. Apart from technical reasons responsible for a poor short-term outcome, long-term patency results after ACDs based anastomoses are still lacking. This case demonstrates an excellent six-year long-term patency of an aortic anastomosis performed with the SJM Symmetry ACD. Certainly, this is only a single case, but it proves the principle to be able to work well over a long time. Another proposed advantage of ACD, namely a decreased neurological dysfunction, is still unproven. Although embolization of atherosclerotic debris from the aorta could be reduced when using connector devices instead of conventional side-clamping, neuro-psychological outcome was not superior compared to standard procedures [2, 10].
In conclusion, in special cases of robotic or beating heart surgery, or in patients with severely calcified aorta, the use of sutureless ACDs may still be attractive. However, technical refinements are important to overcome early graft failure.
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References
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- Lytle BW, Loop FD, Cosgrove DM. Long-term (5 to 12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248–258.[Abstract]
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Abstract
1. Background
