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J Thorac Cardiovasc Surg 2003;126:177-178
© 2003 The American Association for Thoracic Surgery
Cardiopulmonary support and physiology |
Dr Erik W. Jansen (Utrecht, Netherlands). This is an interesting multicenter trial on an innovative coronary artery, actually a general vascular, anastomosis technique. On average, 11.8 self-closing clips were used to create the LITA-to-LAD anastomosis, requiring a mean anastomosis time of 10 minutes and a minimum of 3 minutes. Most were done on OPCAB. So this is really a smooth procedure. That is very good. There were only two conversions, no reoperations for bleeding. What was the rate of extra sutures or clips for hemostasis?
The quality of the anastomosis is well studied by use of the current standards of FitzGibbon, TIMI, and POEM in angiography in 77% of patients. The 6-month patency rate as a standard is good, 94% FitzGibbon grade A, and a favorable percent diameter stenosis. This compares with the patency in all recent off-pump trials.
There is little intravascular nitinol, thus low thrombogenicity. Did the patients receive any antithrombotic medication?
The technique looks very attractive and simple. Basically, it is a classic interrupted technique creating a wide patency, as you showed. Clear advantages are demonstrated. This is an anastomosis technique based on the surgeon’s skill that is highly compliant to vessel structure and presentation, and an interrupted suturing technique that is highly compliant to local calcification and a bifurcation. This device is also probably to port-access applications.
In this study, the bigger ITA and LAD were used, and I assume mainly in Americans. Is there a limitation in the smaller vessels in other populations, with small vessels being 1.25 mm? I saw there were small patients with a mean BMI of 19.7, so this is already a small index. For the diamond LITA anastomosis, 8.0 sutures are required.
Should this technique be considered as a clear intermediate anastomosis technique to the one-shot stapler or as a step up to an automated one-shot stapler in the future?
Dr Wolf. The first question was what was the rate of extra sutures or clips for hemostasis? There were no sutures used in this study, and the average number of clips was the total number of clips used. So if eight clips were used and then there was a bleeding point and an additional clip was used, then that patient had nine clips applied.
The second question was, did the patients receive any antithrombotic medication after operation? That was not part of the protocol. It was up to the surgeon. Most of these patients received aspirin after their operation. But, specifically, there was no need for any other medication.
The third question was, is there a limitation for smaller vessels? There was a change in my practice on the basis of this study. At Ohio State University now, all the fellows are taught this technique, and they like it. This technique is used for all LITA-to-LAD anastomoses, and, if we have a difficult anastomosis, a small-caliber artery or a calcified vessel, we tend to use the clips. With the clips you get a fresh needle for every bite, which causes less damage to the intima. So I prefer these clips for the smaller arteries. And now the company has come out with a smaller clip that is called a "15 clip," and it is equivalent to a 9-0 suture. So I believe that facilitates anastomosis in small vessels.
The last question was, is this an intermediate step to a one-shot? What this really does is signal the emergence of devices in distal coronary anastomosis, and this probably is the beginning, but it is a pretty good start. The company has used this device now in more than 35,000 anastomoses clinically.
Dr G. Hossein Almassi (Milwaukee, Wis). It appears that although it is an interrupted anastomosis, in terms of the time taken to do the anastomosis, it was quick similar to a running anastomosis, about 10 minutes. In this day and age we have to keep in mind how this technology compares with a running suture Prolene as far as the cost is concerned, and are we gaining something there?
Dr Wolf. First of all, if you assume that you are going to perform an interrupted anastomosis and you are going to use 12 sutures or clips, the cost of 12 interrupted silk sutures is $84, 12 interrupted Prolene 7-0 sutures is $120 to $360, depending on the hospital contract; 8-0, of course, would be much more expensive. The U-Clip for 12 sutures is $180. If you compare to just a running suture, then it is going to be one Prolene, which would be, depending on the hospital contract, much less expensive, probably $30, something like that.
Dr F. W. Mohr (Leipzig, Germany). How about the nitinol itself interfering with the anastomosis in terms of visibility in the angiogram; is there any problem? Is there any hidden area?
Dr Wolf. The nitinol is just barely seen on the angiography. If one looks very closely, one can discern the clips, but it does not interfere with the dye study.
Related Article
J. Thorac. Cardiovasc. Surg. 2003 126: 168-177.
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