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J Thorac Cardiovasc Surg 2005;130:1028-1031
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Early and midterm patency of the proximal anastomoses of saphenous vein grafts made with a Symmetry Aortic Connector System

Department of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyusyu City, Fukuoka, Japan.

Received for publication March 17, 2005; revisions received May 22, 2005; accepted for publication May 22, 2005.

^_* Address for reprints: Hideki Kitamura, MD, Cardiovascular Surgery, Kokura Memorial Hospital, Kifunemachi 1-1, Kokurakitaku, Kitakyusyu City, Fukuoka, 802-8555, Japan. (Email: k-hideki{at}sc4.so-net.ne.jp).

	Abstract

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

 
OBJECTIVE: The purpose of this study was to investigate (1) the early and midterm patency rates in saphenous vein grafts that were anastomosed with the Symmetry Aortic Connector System (St Jude Medical, Inc, St Paul, Minn) and (2) risk factors for graft occlusion.

METHODS: Thirty-one patients underwent off-pump coronary artery bypass grafting for proximal saphenous vein graft anastomoses with the aortic connector system. Intraoperative graft flow was studied with transit time flowmetry, and angiography was performed before discharge in 29 cases. Midterm (at least 1 year after the operation) saphenous vein graft patency was assessed by coronary angiography or 3-dimensional coronary computed tomography in 27 cases.

RESULTS: Postoperative angiography demonstrated a 100% patency rate and no significant stenosis at the connector-anastomosed sites. The 1-year patency rate of the saphenous vein grafts with the aortic connector system was 92.6%, with 2 cases of saphenous vein graft occlusion. Both of these cases had low graft flow and poor left ventricular function documented during the operation.

CONCLUSION: Once surgical errors had been ruled out, the 1-year patency rate of proximal saphenous vein grafts anastomosed with the aortic connector system was favorable. Poor left ventricular function and low graft flow during the operation were risk factors for midterm graft occlusion. Selection of the target vessel and its runoff may also be an important determinant of long-term patency.

	Introduction

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

	Material and Methods

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

 
From May 2002 to June 2003, a total of 387 patients underwent isolated OPCAB by the same surgeon at our institution. Total arterial revascularization, including the gastroepiploic artery, was used for treatment of multivessel disease. ^17,18 When the gastroepiploic artery was not available or was ill-suited for use as a graft, ¹⁹ revascularization was achieved with saphenous vein grafts (SVGs). In patients with calcification or atheroma of the ascending aorta, aortic clamping was deferred in favor of proximal anastomoses with the ACS. Of a total of 387 cases, 31 patients underwent proximal SVG anastomoses with the ACS and were evaluated for this study. Emergency cases were defined as any cases in which diagnosis and subsequent surgery took place on the same day.

OPCAB Procedures
The saphenous vein was harvested by trained surgeons with the open technique. Heparin (1 mg/kg) was used to maintain activated clotting time at greater than 250 seconds and was halfway reversed with protamine in nearly all cases after anastomosis. Veins were mounted on the correctly sized device by the primary surgeon according to diameter. Proximal anastomoses were performed first, followed by distal anastomoses. Anastomoses were performed with 7-0 polypropylene continuous suture and assisted by Octopus mechanical stabilization (Medtronic Inc, Minneapolis, Minn).

Graft Evaluation
Intraoperative graft flow was evaluated with a flowmeter (CardioMeds; Medi-Stim, Oslo, Norway) according to the transit time principle. Angiographic evaluation of graft patency was performed before hospital discharge in 29 cases.

Anticoagulation and Antiplatelet Treatments
Heparin (200 U/kg) was administered routinely on postoperative days 1 through 4. Postoperative medical therapy included aspirin (100 mg/d orally) in all cases. Other antiplatelet drugs or warfarin sodium were given to 8 patients because of coexisting arterial disease or atrial fibrillation.

Postoperative Follow-up and Graft Evaluation
Postoperative information was obtained by direct contact with the patients or through telephone conversations with patients or their families. Three-dimensional computed tomography (SOMATOM Sensation 16; Siemens AG, Munich, Germany) was performed at least 1 year after the operation in 26 cases, and those results were evaluated by a reliable radiologist. Coronary angiography was performed in 1 case.

Statistical Analysis
Data were gathered from clinical records and analyzed with StatView version 5.0 (SAS Institute, Inc, Cary, NC). Numeric data were analyzed with the Mann-Whitney and t tests. Categorical data were analyzed by ² analysis. Results are expressed as mean ± SD.

	Results

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

 
Preoperative variables are summarized in Table 1. Mean age at operation was 69.7 years. Mean left ventricular ejection fraction was 60.9%. Operative details are summarized in Table 2. There were no operative or in-hospital deaths, and none of the patients had cerebral infarctions or transient ischemic attacks during hospitalization. Twenty-nine patients underwent postoperative coronary angiography before discharge, with a 100% patency rate and without significant stenosis for proximal anastomoses performed with the ACS.

	Discussion

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

Concerning early graft patency, Donsky and colleagues ¹² reported thrombotic occlusions of ACS sites, and there have been several reports of early occlusion with ACS associated with graft kinking or inadequate graft angle. ^7,8 In this study, results showed acceptable early graft patency. We selected target vessels that seemed to possess enough runoff to distinguish the cause of early occlusion as being from the aortic device rather than from poor runoff. As well as technical aspects, selection of target vessels and routine heparin use might result in good early postoperative patency. The ACS is composed of nitinol, which may cause intimal hyperplasia and lead to midterm stenosis and occlusion. ^13-16 However, the incidences of these events seemed to be higher than with a nitinol stent. ²⁰ Bergsland and associates ¹³ reported that half of the Symmetry grafts were occluded and that an additional 25% had intraconnector stenosis at a mean of 4.8 postoperative months. By contrast, Hirayama and colleagues reported that nitinol stent restenosis was observed in only 17% of cases at 6 months of follow-up. ²⁰ In this study, early graft patency rate was satisfactory, and midterm occlusion rates did not exceed those reported in the literature for hand-sewn polypropylene sutures. ^9,21-23 We speculated that once technical errors, such as graft kinking or inadequate graft angle, were ruled out in the postoperative course, acceptable midterm graft patency could be expected.

However, statistical analysis demonstrated that poor intraoperative graft flow and poor left ventricular function were significantly associated with midterm graft occlusion. These conditions also meant poor runoff. Selection of target vessels and their runoff thus may also be important to long-term patency.

	Conclusion

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

 
Once intraoperative technical errors were eliminated, the midterm patency rate of ACS was acceptable; however, poor runoff contributed to midterm graft occlusion. Selection of target vessels is important for long term patency.

We thank Dr Kenji Makisumi of the Department of Radiology at Kokura Memorial Hospital for performing and interpreting the 3-dimensional computed tomographic studies used in this study.

	References

Top Abstract Introduction Material and Methods Results Discussion Conclusion References

 

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This Article Abstract 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): Hitoshi Okabayashi Michiya Hanyu Yoshiharu Soga Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kitamura, H. Articles by Umehara, E. Search for Related Content PubMed PubMed Citation Articles by Kitamura, H. Articles by Umehara, E.