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J Thorac Cardiovasc Surg 2004;127:269-270
© 2004 The American Association for Thoracic Surgery
Brief communication |
a Department of Thoracic and Cardiovascular Surgery, University of Tennessee, Methodist University Hospital, Memphis, Tenn, USA
Received for publication June 4, 2003; accepted for publication July 14, 2003. * Address for reprints: G. Phillip Schoettle, Jr, MD, Clinical Associate Professor of Surgery, Department of Thoracic and Cardiovascular Surgery, Methodist University Hospital, 1325 Eastmoreland, Suite 220, Memphis, TN 38104, USA
Patients undergoing coronary artery bypass graft surgery (CABG) today are older and have increased comorbidities than those a decade ago.1 In an effort to maintain favorable morbidity and mortality data, many cardiac surgeons have begun to perform CABG with less invasive techniques. Avoiding cardiopulmonary bypass and minimizing aortic manipulation with sutureless aortic connectors are two ways to potentially achieve this goal.2,3 A review of patients with the Symmetry aortic connector (St Jude Medical, Inc, Minneapolis, Minn), however, has shown a high percentage of early graft occlusions.
Clinical summary
I report a retrospective review of two patient groups undergoing CABG. In group A, 323 patients underwent surgery from October 2000 through September 2001. In group B, 305 patients underwent surgery from October 2001 through September 2002. All operations were performed by the same surgeon, and 95% of all procedures in both groups were done without cardiopulmonary bypass.
Group A patients had the proximal vein–aorta anastomoses done in the usual fashion with a partial occlusion clamp on the aorta and hand-sewn grafts. The patients in group B received saphenous vein–aorta connections with the St Jude Symmetry device with no aortic clamping. All patients had operative graft patency confirmed with the use of the Medistem transit time flow probe (Medtronic, Inc, Minneapolis, Minn). Patients in both groups received continuous postoperative aspirin and received clopidogrel daily for 2 months.
After institutional review board approval was obtained, a catheterization laboratory database was used to determine which patients had undergone repeat cardiac catheterization after the CABG procedure. End points of reoperative CABG and death were reported as observed. The decision to perform repeat cardiac catheterization was made by each patient's cardiologist and most commonly was based on a clinical suspicion of recurrent ischemia.
To date, 40 patients in group A have undergone repeated cardiac catheterization, and of 71 venous grafts studied, 61 were widely patent. Forty-five patients in group B have undergone repeated cardiac catheterization, and of 88 venous grafts studied, 39 were totally occluded. Seventeen had 90% or greater stenosis, and 15 had 50% or greater stenosis (Table 1). These stenoses uniformly occurred at the connector site. Among the patients studied, this represented an 80% rate of occlusion or stenosis with the proximal venous graft connectors.
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Discussion
During the past decade many cardiac surgeons have adopted new technology in attempts to make CABG less invasive. The Symmetry aortic connector is primarily used to minimize trauma to the aorta from clamping. Potential benefits include a decreased incidence of stroke from aortic embolization and prevention of aortic dissection from the partial occlusion clamp. Other possible benefits are a technically superior proximal anastomosis and rapidity of use with decreased operative time.
After Food and Drug Administration approval in 1998 and training by St Jude Medical in its use (September 2001) I exclusively incorporated the proximal anastomotic device into my CABG practice. After 12 months, it was apparent that the incidence of saphenous vein occlusion or stenosis associated with the proximal connector was not compatible with my previous off-pump CABG experience. The large number of aortic venous graft connector stenoses or occlusions seen in group B have required multiple interventions—either PTCA and stenting, reoperative CABG, or aggressive medical therapy in patients not amenable to repeated intervention. The patients in group A, although subjected to a longer period of observation, have not had an unexpected number of venous graft occlusions, nor have they required the large number of interventions needed by those in group B.
The 4 sudden deaths among the patients with connector use and the documented venous graft occlusions or stenoses leading to early reoperative CABG are cause for concern. I also note that the patients who require PTCA and stents to relieve proximal connector venous graft stenosis are likely subject to the restenosis rate inherent in stented vessels.
The proximal connector device is appealing for the reasons mentioned previously. For facilitated anastomoses to justify the expense and replace traditional hand-sewn grafts, however, they must have equal or better short- and long-term patencies. Despite potential benefits of sutureless aortic connections, this patient review demonstrates unacceptable saphenous venous graft stenosis and occlusion with the use of the Symmetry aortic connector.
References
This article has been cited by other articles:
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  C. Vicol, S. Eifert, M. Oberhoffer, P. Boekstegers, and B. Reichart Mid-term patency after magnetic coupling for distal bypass anastomosis in coronary surgery. Ann. Thorac. Surg., October 1, 2006; 82(4): 1452 - 1456. [Abstract] [Full Text] [PDF]
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 R. G. Kachhy, D. F. Kong, E. Honeycutt, L. K. Shaw, and R. D. Davis Long-Term Outcomes of the Symmetry Vein Graft Anastomosis Device: A Matched Case-Control Analysis Circulation, July 4, 2006; 114(1_suppl): I-425 - I-429. [Abstract] [Full Text] [PDF]
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