J Thorac Cardiovasc Surg 2004;128:330-331
© 2004 The American Association for Thoracic Surgery
The return of the coronary stapler: Will a new technique overcome an old obstacle?
Igor E. Konstantinov, MDa
a Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
To the Editor:
I read with greatest interest the recent article by Dr Suyker and colleagues.1 The authors used a circular coronary stapler to perform an end-to-side left internal thoracic artery (LITA)–to–left anterior descending artery (LAD) anastomosis in 10 pigs. The procedure was performed on the beating heart through a partial median sternotomy. Patency of the anastomoses was confirmed by means of postmortem angiography, and histomorphologic evaluation performed at 5 weeks after the operation showed a normal healing response.
A few comments seem to be appropriate and of interest to the readership of the Journal. The clinical use of circular coronary stapling has a short yet fascinating history.2 Vladimir P. Demikhov (1916-1998) used the coronary stapling device in the early 1950s to make LITA-to-LAD end-to-end anastomoses in dogs and cadavers.3 On the basis of Demikhov's experiments, Vasilii I. Kolesov (1904-1992) first clinically applied the coronary vascular stapler (VCA-4) on March 22, 1967, when he constructed an end-to-end anastomosis between the LITA and LAD in a 52-year-old man with class IV angina.4 Three years later, the patient remained free of angina. Kolesov subsequently used modified staplers with prolonged bushing (Figure 1, A) and vacuum suction to hold the LITA wall while the stapling was performed (US patent 4,350,160 of September 21, 1982).2 The coronary angiography performed almost 4 years after the operation with this vacuum-facilitated stapler demonstrated patent end-to-end anastomosis (Figure 1, B). Thus it has already been demonstrated that coronary stapling can be successfully applied clinically. There were 3 main obstacles that precluded the use of coronary staplers in the early era of coronary surgery.
View larger version (97K):
[in this window]
[in a new window]
|
Figure 1. A, Vascular circular stapler with prolonged bushing (VCA-PB) applied by V. I. Kolesov and E. V. Kolesov in coronary surgery: 1, coronary artery; 2, internal thoracic artery; 3, incision in the coronary artery; 4, bushing; and 5, prolonged bushing. From Kolesov VI. The Surgery of Coronary Arteries of the Heart. Leningrad: Meditsina Publishing; 1977. p. 163. B, Angiogram done in the late 1960s demonstrating patent end-to-end anastomosis (arrow) applied by vacuum-facilitated stapler 3 years and 7 months after the operation. Courtesy of Dr Evgenii V. Kolesov.
|
|
First, it was easier and faster to perform the anastomosis by hand either with or without cardiopulmonary bypass. The modern demands of achieving minimally invasive coronary surgery through ever-shrinking incisions reversed this. Both Kolesov's and Suyker's staplers could be adjusted to video-assisted robotic coronary surgery.
Second, it was not possible to make an end-to-side anastomosis with those early staplers. The ingenious stapler described by Dr Suyker and colleagues resolved this problem.
The third and most significant obstacle was the inability of the early staplers to bite through the heavily atherosclerotic vascular wall. They chewed on it. The Kolesov stapler overcame this obstacle in the late 1960s. It produced a perfect anastomosis in heavily atherosclerotic coronary arteries. Will the new stapler described by Dr Suyker and colleagues overcome this obstacle too?
It never ceases to amaze me how often old ideas, which seemed utterly impractical for many years, return to life. It seems that what has been accomplished in surgery never dies but rather remains dormant for a number of years, waiting to be rediscovered. The time of robotic and minimally invasive coronary surgery has come, and the coronary staplers are evolving under the pressure of modern technology to find their new applications. Are these stapling devices here to stay this time?
Last but not least, I would like to congratulate Dr Suyker and colleagues on their fine experimental study. I am anxiously awaiting the results of their clinical experience and hope that their stapler will be more successful than its predecessors. If it can successfully bite through the atherosclerotic vascular wall, it will have an enormous effect on minimally invasive coronary surgery.
 |
References
|
|---|
- Suyker WJL, Buijsrogge MP, Suyker PT, Verlaan CWJ, Borst C, Grundeman PF. Stapled coronary anastomosis with minimal intraluminal artifact: the S2 anastomosic sys-tem in the off-pump porcine model. J Thorac Cardiovasc Surg. 2004;127:498–503[Abstract/Free Full Text]
- Konstantinov IE. Circular vascular stapling in coronary surgery. Ann Thorac Surg. 2004. In press
- Demikhov VP. Experimental transplantation of vital organs [authorized translation from Russian by Basil Haigh]. New York: Consultant' Bureau; 1962.
- Kolesov VI, Kolesov EV, Gurevich IY, Leosko VA. Vasosuturing apparatuses in surgery of coronary arteries. Med Tekh. 1970;6:24–28
Top
References