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J Thorac Cardiovasc Surg 2003;125:414-417
© 2003 The American Association for Thoracic Surgery

Brief Communications

First experience with the St Jude Medical, Inc, Symmetry Bypass System (Aortic Connector System)

From the Department of Thoracic and Cardiovascular Surgery^a and the Department of Cardiology,^b Heart Center North Rhine-Westfalia, Ruhr-University of Bochum, Bad Oeynhausen, Germany.

Received for publication April 3, 2002. Accepted for publication May 30, 2002. Address for reprints: Lech Hornik, Heart Center North Rhine-Westphalia, Department of Thoracic and Cardiovascular Surgery, Georgstrasse 11, Bad Oeynhausen North Rhine-Westphalia 32545, Germany.

View larger version (117K): [in this window] [in a new window]   Tenderich and Hornik (left to right).

If atheroma or calcification of the aortic wall are present, clamping is often impossible, and it remains unclear whether the use of the partial occlusion clamps on the pulsating aorta during off-pump surgery will increase the risk of iatrogenic injuries.

However, the St Jude Medical, Inc, Symmetry Bypass System (Aortic Connector System [ACS]) presents an alternative way of creating the proximal anastomosis of saphenous vein grafts. ² It avoids aortic bite clamping and reduces the need for aortic manipulation.

Patients and methods

Between April and October 2001, 69 of 70 proximal anastomoses were consecutively performed in 45 patients aged 36 to 89 years (mean, 68.3 years) by using the ACS. Eighteen internal thoracic artery grafts, 70 autologous vein grafts, and 1 radial artery graft were used, for a total number of 108 peripheral anastomoses with an average of 2.4 anastomoses per patient. Five patients were operated on in a conventional manner with the heart-lung machine. Of 31 off-pump patients, 9 patients had to be switched to on-pump therapy, with a conversion rate of 29%.

In 4 patients with postoperatively de novo angina pectoris, coronary angiography was indicated, showing severe stenosis of the proximal anastomoses in each case.

In all cases the stenosis appeared several weeks after discharge from the hospital. Three patients underwent a redo procedure using the heart-lung machine and partial occlusion clamp, and one patient was treated by means of dilatation.

Patient 1
A 52-year-old woman had a history of dialysis since 1998 and 3-vessel disease. Preoperatively, she was treated with nitrate and heparin because of unstable angina pectoris after 2 fruitless attempts at angioplasty of the right coronary artery (RCA). There was no myocardial infarction. Ejection fraction was 74%. Elective on-pump coronary artery surgery was performed on June 28, 2001, and indication for use of the ACS was a severe calcified ascending aorta. Two single-vein grafts to the left anterior descending coronary artery (LAD) and the posterior descending coronary artery (PDA) were placed. A short time after discharge, the patient had angina pectoris. Cardiac catheterization (September 19, 2001) showed an occlusion of the PDA bypass next to the stenosed proximal ACS anastomosis (Figure 1), as well as a subtotal stenosis of the proximal anastomosis of the ACS-LAD graft (Figure 2). On September 21, the patient had an acute inferior myocardial infarction and a maximum creatine kinase level of 400 U/L. Redo surgery was performed successfully on October 18, 2001, in a conventional manner by using cardiopulmonary bypass and placing 2 single-vein grafts to the RCA and the marginal branch of the circumflex artery, as well as the left internal thoracic artery to the LAD. Histopathologic examination of the proximal parts of the explanted PDA bypass showed severe intimal fibrosis, as well as organized and partially revascularized thrombosis.

View larger version (139K): [in this window] [in a new window]   Fig. 1. Occlusion of the saphenous vein graft to the posterior descending coronary artery next to the stenosed proximal ACS anastomosis.

View larger version (160K): [in this window] [in a new window]   Fig. 2. High-grade stenosis of the proximal vein graft anastomosis to the LAD performed with the ACS.

View larger version (152K): [in this window] [in a new window]   Fig. 3. High-grade stenosis of the proximal vein graft anastomosis to the RCA related to the ACS.

View larger version (168K): [in this window] [in a new window]   Fig. 4. Stenosis of the proximal anastomosis of the saphenous vein graft to the Dg performed with the ACS.

At the end of 2001, he again had angina pectoris, and cardiac catheterization showed a high-grade stenosis of the proximal (Figure 5) and peripheral anastomosis. Redo surgery was successfully performed on January 7, 2002, by using cardiopulmonary bypass and partial occlusion clamping.

View larger version (139K): [in this window] [in a new window]   Fig. 5. High-grade stenosis of the proximal anastomosis of the sequential LAD-Dg vein graft related to the ACS.

View larger version (121K): [in this window] [in a new window]   Fig. 6. High-grade stenosis of the LAD-Dg graft in the middle part of the bypass proximal to venovenous anastomosis.

View larger version (124K): [in this window] [in a new window]   Fig. 7. Stenosis of the proximal anastomosis of the LAD-Dg graft related to the ACS.

Using a partial occlusion clamp for proximal anastomosis in aorta-coronary bypass surgery bears the risk of iatrogenic dissections or embolic complications for various reasons. These complications are more likely in patients with the risk factors of atheroma, calcification, medial necrosis, a thin fragile aorta, or an increased wall tension during off-pump surgery. ¹ St Jude Medical, Inc, offers a novel sutureless connector system for creation of the proximal anastomosis of saphenous vein grafts without the need for clamping of the aorta. ² The vein hook is made of nickel titanium (Nitinol), a biocompatible alloy, and published results show that the ACS does not seem to impair endothelial function.^*

However, 4 of 45 patients treated with the ACS between April 2001 and October 2001 had a proximal ACS-related stenosis, thrombosis of the saphenous vein graft, or both, with the need for reintervention within 6 months postoperatively. One resected vein graft showed a partially revascularized thrombosis of the proximal graft. Genesis of the stenoses is unknown. We did not observe any kinking of any of the implanted grafts at the aortic take-off point as a probable cause. A possible explanation could be the unavoidable learning curve, resulting in an undersizing or oversizing or the incomplete piercing of the saphenous vein, followed by rolling up of the intima and resulting thereby in graft stenosis or occlusion, mechanical alteration of the intima itself, or bioincompatibility of the device. The significance of the ACS in the genesis of proximal graft stenosis, thrombosis, or both has to be elucidated by means of further investigations.

Footnotes

^*Verma S, Ko L, Fedak PWM, Cusimano RJ, Yau T. The St Jude Medical sutureless aortic anastomotic connector does not impair endothelial function in human saphenous veins. Unpublished data.

References

1. Hagl C, Ergin A, Galla JD, Spielvogel D, Lansman S, Squiteri RP, et al. Delayed chronic type A dissection following CABG. J Card Surg. 2000;15:362-7.[Medline]
   
2. Eckstein FS, Bonilla LF, Engelberger L, Stauffer E, Berg TA, Schmidli J, et al. Minimizing aortic manipulation during OPCAB using the symmetry aortic connector system for proximal vein graft anastomoses. Ann Thorac Surg. 2001;72:S995-8.[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): K. Minami Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hornik, L. Articles by Koerfer, R. Search for Related Content PubMed PubMed Citation Articles by Hornik, L. Articles by Koerfer, R. Related Collections Coronary disease Minimally invasive surgery