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Revival of the side-to-side approach for distal coronary anastomosis
© Song et al; licensee BioMed Central Ltd. 2007
Received: 01 February 2006
Accepted: 06 January 2007
Published: 06 January 2007
Side-to-side anastomosis was employed by just ten proportional stitches while performing distal anastomosis during coronary artery surgery. This technique is simple and quick. Here this simple technique is described in detail and the postoperative status of grafted conduits is reported.
As new devices for automated anastomosis are developed, hand-sewn anastomosis appears to be on the wane. As for proximal anastomosis during coronary artery bypass grafting, several aortic connecting devices have some favorable prospects although their safety has not been yet been proven . In addition, regarding distal anastomosis, new anastomosing devices, such as the retinol interrupted anastomosis device and magnetic device, have been developed , with some favorable prospects. As surgeons who take pride in craftsmanship and proficiency, we have been working on our skill and employ a technique of side-to-side anastomosis with just ten proportional stitches by hand during coronary surgery.
From April 2003 to March 2004, 186 distal anastomoses were performed by this technique; left internal mammary artery was used in 93 anastomoses, right internal mammary artery was used in 21, right gastroepiploic artery was used in 37, and radial artery was used in 35. 52 anastomoses were performed off-pump and the remaining 134 anastomoses were performed on-pump. We exclude vein grafts in this study and always used in-situ arterial grafts to avoid aortic manipulationin in off-pump cases. The overall patency rate of the anastomosis was 100%, and was usually confirmed by postoperative coronary angiography on the 10th postopearitve day. Contrary to general fears and briefings, a clogged up end of a graft did not affect anastomosis. The average time for completing one anastomsis was 6 minutes and 17 seconds (standard deviation was 69 seconds). Surprisingly, there was only three anastomosis requiring additional sutures to stop bleeding from anastomosis through this series. All grafts were examined, scrutinizing the functioning status by means of intraoperative transit Doppler flow meter (Medistim, Oslo, Norway) after termination of cardiopulmonary bypass and reversal of heparin. Good functioning arterial grafts could be determined by ascertaining the diastolic dominant flow pattern of the flow, perfusion index less than 5.0, and a flow more than 10 ml/min. In this series, the average flow was as follows; left internal mammary artery 39 +/- 11 ml/min, right internal mammary artery 43 +/- 4 ml/min, right gastroepiploic artery 18 +/- 10 ml/min, and radial artery 28 +/- 13 ml/min. Two grafts were judged to be mal-functioning as no diastolic component was shown on the Doppler. The distal ends of these anastomoses were opened by removing the clips and the anastomoses were examined by direct vision. We passed a 1.0 mm or 1.5 mm probe to make sure that they were wide open.
The two grafts were found to be vasospastic and were treated by a topical spray of warm milrinone solution.
This technique has not yet been utilized in on-pump cases needing vein grafts, because clogging of vein grafts using traditional end-to-side anastomosis has not yet occurred. We are now working on an evaluation of vein graft status using this technique.
Side-to-side anastomosis has four advantages . First, inserting proportional sutures is easy and is not misleading. The coronary incision and graft incision can be perfectly matched by applying ten proportional stitches. Second, it is easy to confirm anastomosis if there is a doubt. All that is necessary is to reopen the anastomosis via the distal end of the graft. An anastomosis need not be re-sutured. Third, the distal end of the graft can be held beyond the surgical clip by forceps without damaging the arterial graft, making it easier to perform anastomosis . Fourth, side-to-side anastomosis is superior to end-to-side-anastomosis in the light of fluid dynamics . Bonert, et al., from Toronto stated that a parallel configuration has fewer areas of low wall shear stress and low spatial wall shear stress gradients, and therefore is preferred over the diamond for maintaining graft patency.
We conclude that this technique is attractive and straightforward because it needs only seven minutes to finish, gives direct vision of anastomosis in the event of a problem without the need to repeat sutures, and gives relief in terms of superior fluid dynamics in the blood flow of anastomosis when completing an anastomosis.
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