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J Thorac Cardiovasc Surg 2002;124:397-399
© 2002 The American Association for Thoracic Surgery

Brief Communications

Thrombotic occlusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the Symmetry aortic connector system

From the Departments of Internal Medicine (Division of Cardiology),^a Pathology,^b and Cardiothoracic Surgery^c and the Heart and Vascular Institute,^d Baylor University Medical Center, Dallas, Tex.

Received for publication Jan 22, 2002. Accepted for publication Feb 16, 2002. Address for reprints: Baron L. Hamman, MD, Baylor University Medical Center, Division of Cardiothoracic Surgery, 3500 Gaston Ave, Dallas, TX 75246 (E-mail: Bhamman{at}CDM.net).

St Jude Medical (St Paul, Minn) received Food and Drug Administration approval in May 2001 for a device to aid in the anastomosis of vein grafts to the aorta during coronary artery bypass grafting. This device, known as the Symmetry aortic connector system, allows the surgeon to connect a vein graft to the aorta without the use of sutures or an aortic clamp. To our knowledge, no reports have appeared describing complications from the use of this device. In this report we describe 2 patients who had complete thrombotic occlusions of the aortic ostia of saphenous venous grafts early postoperatively after the use of this device.

Clinical summaries

Patient 1
A 66-year-old obese (body mass index, 45 kg/m²) woman with type 2 diabetes mellitus, systemic hypertension, abdominal aortic aneurysm resection 4 years earlier, and heparin-induced thrombocytopenia was admitted for unstable angina pectoris. Coronary angiography disclosed that the left circumflex artery arose from the right sinus of Valsava and coursed in a retroaortic position to the left atrioventricular sulcus and distally was small and diffusely narrowed. The left anterior descending coronary artery was totally occluded in its midportion, and the right coronary artery was narrowed up to 75% in diameter. Left ventricular angiography disclosed normal systolic function with an estimated ejection fraction of 70%.

Off-pump coronary artery bypass grafting was performed through a left thoracotomy. Two saphenous venous grafts were attached to the ascending aorta by using the Symmetry system. One graft was anastomosed to the posterior descending branch of the right coronary artery, and the other graft was anastomosed to an obtuse marginal branch of the left circumflex coronary artery. The left internal thoracic artery (LITA) was anastomosed to the left anterior descending artery, but poor blood flow was noted through it, and a proximal obstruction of the LITA was assumed to be present. As a consequence, the LITA was severed, and the remaining 3-cm end was anastomosed to the vein graft supplying the obtuse marginal coronary artery, creating a Y-type composite graft. Lepirudin, instead of heparin, was used during the procedure because circulating heparin-associated antibodies were present.

The patient was extubated on the first postoperative day and transferred to the telemetry floor on aspirin and furosemide. Her recovery was complicated by persistent hypoxemia and increasing oxygen requirements despite rigorous diuresis. On postoperative day 7, severe hypoxemia and bradycardia occurred, followed by asystole; appropriate resuscitation efforts were unsuccessful.

Necropsy disclosed thrombi completely filling the ostia of both vein grafts at their anastomosis with the ascending aorta (Figure 1). The lumen of the vein graft to the posterior descending artery was otherwise widely patent. The LITA and the vein graft to the obtuse marginal artery were completely filled with thrombus. The left ventricular cavity was of normal size, and the heart weighed 515 g. A small area of necrosis (acute myocardial infarction) was seen in the myocardium adjacent to the anastomotic site of the vein graft to the obtuse marginal coronary artery.

View larger version (100K): [in this window] [in a new window]   Fig. 1. Patient 1: This photograph shows thrombus in the ostium of each of the 2 Symmetry aortic connector devices.

Off-pump coronary artery bypass surgery through a left thoracotomy was performed. The Symmetry system was used in the anastomosis of a saphenous venous graft to the descending aorta, and it was then anastomosed to the obtuse marginal coronary artery. He was transferred to the telemetry floor on aspirin, metoprolol, and furosemide. On postoperative day 4, he had recurrent chest pain that was unresponsive to nitrates. An electrocardiogram now showed new T-wave inversions in the lateral precordial leads, and the troponin level was increased (1.9 ng/mL). Coronary angiography showed that contrast material injected into the left main coronary artery filled the distal end of the vein graft through the obtuse marginal coronary artery. However, contrast material injected into the descending aorta demonstrated total occlusion of the new vein graft at its ostium (Figure 2). Balloon angioplasty and stent placement was performed to the left main artery and the proximal portion of the circumflex artery with excellent angiographic results. The patient had no recurrence of chest pain and was discharged 2 days later.

View larger version (81K): [in this window] [in a new window]   Fig. 2. Patient 2: Coronary angiogram. Left, This photograph was taken after injection of contrast material into the left main (LM) coronary artery. The distal end of the saphenous venous graft (SV) fills through the left obtuse marginal (LOM). LAD, Left anterior descending artery; LC, left circumflex. Right, This photograph was taken after injection of contrast material into the descending aorta at the sight of the saphenous venous conduit (arrow). The ostium of the conduit is occluded. The upper right portion shows residual contrast material in the saphenous venous graft, which remained after the injection into the left main coronary artery.

The Symmetry aortic connector system is a nitinol metallic device that functions somewhat like a grommet to attach a saphenous vein to a punched out portion of the aorta. This anastomosis is performed without sutures or an aortic clamp. This system has several potential advantages over the traditional suturing method. First, the time required to perform the anastomosis is reduced, and that might shorten recovery time. Second, minimizing aortic manipulation might reduce the risk of embolic events and thus reduce the incidence of neurologic complications. Finally, the size of the incision might be reduced because only limited exposure is needed to safely and consistently deploy the connector. Eckstein and associates ¹ reported on their initial experience with this device in 20 patients undergoing off-pump coronary artery bypass surgery. They had excellent results, with no patient having any cardiac-related event within 3 months.

Each of the 2 patients described herein had thrombotic occlusion of the aortic ostia of saphenous venous grafts early after bypass surgery with the Symmetry aortic connector system. Such an occurrence in the early postoperative period with standard suture techniques is exceedingly uncommon. One of us (B.L.H.) has used this device in many patients, and the 2 described herein were the first encountered with known thrombotic complications at the aortic anastomotic sites.

Before concluding that the thrombotic complications were the direct result of one or more defects in the Symmetry system, several factors must be considered. Patient 1 had a history of heparin-induced thrombocytopenia with circulating antibodies, a circumstance recognized to be associated with a prothrombotic state. The saphenous venous graft attached to the left obtuse marginal coronary artery in the patient was totally occluded by thrombus, as was the LITA attached to it. The saphenous venous graft to the posterior descending artery, in contrast, was widely patent, except at its ostium. Patient 2 had the aortic anastomosis performed in the descending thoracic aorta. Both patients were extremely obese (grade 3/3) and had diabetes mellitus and systemic hypertension, features characteristic of the metabolic syndrome (insulin resistance syndrome), a condition recognized to be a prothrombotic state. ^2,3 Whether these complicating factors played a role in the thrombotic occlusions of the aortic ostia in these 2 patients is, of course, unclear.

It is possible that the acute thrombosis seen in these 2 patients is similar in pathophysiology to that seen in acute stent thrombosis. The early experience with coronary artery stenting showed that acute thrombosis was a significant limiting factor. Improvements in stent design, deployment techniques, and the use of antiplatelet agents (ticlopidine and clopidogrel) dramatically reduced the incidence of acute stent thrombosis to less than 1%. ⁴ Although the use of clopidogrel is standard therapy after coronary artery stenting, its use after placement of the Symmetry device has not been carefully studied.

In summary, 2 patients are described who underwent off-pump coronary artery bypass grafting with the Symmetry aortic connector system for the aortic anastomosis. Necropsy in one patient showed that the ostia of both aortic anastomotic sites were occluded by thrombus. In the second patient the aortic anastomotic site (in descending thoracic aorta) was demonstrated by angiography to be occluded. Although both patients had conditions predisposing to thrombus, such thrombotic occlusion of the aortic anastomotic sites are exceedingly rare in patients with an aortic anastomosis inserted by means of suture.

References

1. Eckstein FS, Bonilla LF, Strauffer E, Berg TA, Schmidli J, Carrel TP. Minimizing aortic manipulation during OPCAB using the Symmetry aortic connector system for proximal vein graft anastomosis. Ann Thorac Surg. 2001;72:S995-8.[Abstract/Free Full Text]
   
2. Grundy SM. Hypertriglyceridemia, atherogenic dyslipidemia, and the metabolic syndrome. Am J Cardiol. 1998;81:18B-25B.[Medline]
   
3. Juhan-Vague I, Alessi MC, Vague P. Increased plasma plasminogen activator inhibitor 1 levels: a possible link between insulin resistance and atherothrombosis. Diabetologia. 1991;34:457-62.[Medline]
   
4. Schog A, Neumann FJ, Kastrati A, Schuhlen H, Blasini R, Hadamitzky M, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 1996;334:1084-9.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Baron L. Hamman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Donsky, A. S. Articles by Hamman, B. L. Search for Related Content PubMed PubMed Citation Articles by Donsky, A. S. Articles by Hamman, B. L. Related Collections Coronary disease