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J Thorac Cardiovasc Surg 1999;117:117-125
© 1999 Mosby, Inc.

SURGERY FOR ADULT CARDIOVASCULAR DISEASE

A NOVEL ONE-SHOT ANASTOMOTIC STAPLER PROTOTYPE FOR CORONARY BYPASS GRAFTING ON THE BEATING HEART: FEASIBILITY IN THE PIG

From the Departments of Cardiology and Cardiothoracic Surgery, Heart Lung Institute, Utrecht University Hospital,^a Utrecht, The Netherlands, and United States Surgical Corporation,^b Norwalk, Conn.

The study and R.H.H., C.W.J.V., and P.F.G. were supported by a grant from the Utrecht University Hospital (1995/B903).

Received for publication May 5, 1998. Revisions requested June 29, 1998. Revisions received July 23, 1998. Accepted for publication Sept 8, 1998. Address for reprints: Cornelius Borst, MD, PhD, Professor of Experimental Cardiology, Utrecht University Hospital (Room G02.523), PO Box 85500, 3508 GA Utrecht, The Netherlands.

Objective: The nonpenetrating, arcuate-legged clip has proved its ability to provide a high-quality microvascular anastomosis. This study assessed the feasibility of constructing a coronary end-to-side anastomosis on the beating heart with a novel mechanical, sutureless anastomotic device that applies 12 circumferential clips simultaneously.
Methods: In 14 consecutive pigs (70–90 kg), the left internal thoracic artery (diameter, 3 mm) was grafted to the left anterior descending coronary artery (diameter, 3 mm) by means of a one-shot anastomotic stapler prototype. Endothelial denudation, medial necrosis, and intimal hyperplasia were analyzed quantitatively and compared with those seen in conventionally sutured anastomoses (n = 4).
Results: In 8 of 14 anastomoses, the one-shot anastomotic stapler successfully applied all 12 clips circumferentially across the everted arteriotomy edges. In the remaining, either 1 (n = 4) or 3 and 4 adjoining malaligned clips had to be replaced manually with a single-clip applicator. Coronary occlusion was limited to approximately 3 minutes. At follow-up, all anastomoses were patent angiographically. At 2 days, in 2 of 7 cases, a local coronary dissection was observed, and there was a considerable loss of endothelial cells and medial damage. At 28 days, however, minimal intimal hyperplasia was seen at the anastomotic lining, although more pronounced when compared with conventionally sutured anastomoses.
Conclusions: The one-shot anastomotic stapler prototype enabled short-occlusive (3 minutes), sutureless end-to-side grafting on the beating porcine heart. In spite of early endothelial and medial damage and 2 local dissections, all anastomoses remained patent with minimal intimal hyperplasia at 4 weeks.

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