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Initial Anastomosis from the Surgeon's Viewpoint. The original coronary artery is shown at the top and the graft artery is shown at the bottom. In this technique, the graft artery is placed near the surgeon. This suturing technique begins at the point two-fifths halfway towards the arteriotomy near heel position. The suture is made from outside of the graft to inside of the graft. Consequently the next suture is made at the corresponding point of coronary artery from inside of coronary artery to outside of coronary artery. The same forehand continues to place stitches in a clockwise rotation. Black and white segments are hypothetical segments and they correspond to the one-tenth division of anastomosing orifice. Consecutively single-parachute stitches are done up to the fifth point.
Source publication
Side-to-side anastomosis was employed by just ten proportional stitches while performing distal anastomosis during coronary artery surgery. This technique is simple and quick. Here this simple technique is described in detail and the postoperative status of grafted conduits is reported.
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Citations
... This implies The second step of the procedure consisted of a laserinduced perforation of the solder fixed to the vessel wall on both sides. Laser ablation and vaporization of vascular tissue have been described since 1982 [17,18] and have been successfully used for the revascularization of coronary vessels and peripheral vessels [19,20] with various laser sources. Regardless of the laser used, the goal is to ablate atheromatous plaques and promptly restore blood flow while creating minimal debris and minimal damages to the vessel wall. ...
The common limitation of surgical revascularization procedures for severe tissue ischemia due to cardiovascular diseases is the need to interrupt blood flow during the intervention. We aim to introduce a new technique that allows a sutureless, non-occlusive revascularization. A 3-step technique was developed using rabbit’s aorta to simulate a side-to-side anastomosis model. It enables the creation of a bypass circuit for revascularization. The first step was the soldering of 2 vessels in a side-to-side fashion based on the laser-assisted vascular anastomosis (LAVA) principle using a diode laser emitting irradiation at 810 nm with an albumin-based solder patch between them, followed by the creation of a channel within the patch using either a holmium-doped yttrium aluminum garnet laser (Ho:YAG) at λ = 2100 nm or a xenon-chloride excimer laser (XeCl) at λ = 308 nm. Thereby, a bypass circuit was created, thus allowing a non-ischemic revascularization. The system was deemed functional when a flow was observed across the anastomosis. The highest average tensile strength recorded after side-to-side LAVA using a diode laser power of 3.2 W for 60 s was 2278.6 ± 800 mN (n = 20). The Ho:YAG laser created the channels with less tension on the anastomosis than the excimer laser. Histological analysis showed limited thermal damage and good patch-tissue adaptation. The preliminary results of this feasibility study outline the foundations for an entirely sutureless laser-assisted revascularization procedure. The next studies will evaluate the rheological parameters across the bypass circuit to optimize the post-anastomotic flow.
... Moreover, Noori et al. [6] studied the flow patterns of different end-to-side techniques and found that only the Miller-cuff technique appears to have better flow patterns due to its wider anastomotic cavity. Furthermore, clinical studies on side-toside anastomosis showed that this technique has larger patency rates and better fluid dynamics [7,8]. Our study does not deal with the hemodynamic analysis and flow patterns of side-to-side related anastomosis. ...
... By combining Eqs. (1) through (8), the response of the two elements in terms of axial forces, shear forces, moments, radial and tangential displacements can be derived. For element I ( 0 ≤ θ Ι ≤ π ) the normalized response is given by ...
Suture line stress concentration and intimal hyperplasia are related to the long-term complications of end-toside and side-to-side anastomosis. Several factors, such as hemodynamic effects, biological activities and the mechanical properties of the blood vessels, are identified to influence the problem. Yet, it is not completely clear which are the factors that influence most the long-term complications and in what specific way. This study aims to examine if elastic (compliance) mismatch increases the stress concentration and intimal thickening at the suture line. Better compliance may be obtained by using grafts with similar mechanical properties to the host artery or by anastomosis techniques that utilize vein patches and cuffs (Taylor-patch and Miller-cuff anastomosis). The anastomosis model used in this study is a circular cylindrical system consisting of two semi-cylinders, interconnected by two hinges. The internal blood pressure is applied on the arterial walls. The static and dynamic responses are analytically derived in terms of radial and tangential displacements, internal forces and strains of the two blood vessels and rotation of their cross-section. Results suggest that increased elastic mismatch between the artery and the graft may promote elevated intimal thickening due to large incompatible angles at the junction, whereas there is no correlation between elastic mismatch and elevated stress concentration at the suture line. Another interesting application of the present model is the patching of arteries as applied in carotid endarterectomy.
... Side-to-side anastomoses have been described to connect the left internal mammary artery (LIMA) to target coronary vessels for the purpose of reducing surgical damage on LIMA [12]. Song et al. also introduced a technique of side-to-side anastomosis with just ten proportional stitches by hand for artery grafts [13]. In vein sequential grafting, side-to-side anastomoses are usually performed for the middle anastomoses [6]. ...
Background
End-to-side anastomoses to connect the distal end of the great saphenous vein (GSV) to small target coronary arteries are commonly performed in sequential coronary artery bypass grafting (CABG). However, the oversize diameter ratio between the GSV and small target vessels at end-to-side anastomoses might induce adverse hemodynamic condition. The purpose of this study was to describe a distal end side-to-side anastomosis technique and retrospectively compare the effect of distal end side-to-side versus end-to-side anastomosis on graft flow characteristics.
Methods
We performed side-to-side anastomoses to connect the distal end of the GSV to small target vessels on 30 patients undergoing off-pump sequential CABG in our hospital between October 2012 and July 2013. Among the 30 patients, end-to-side anastomoses at the distal end of the GSV were initially performed on 14 patients; however, due to poor graft flow, those anastomoses were revised into side-to-side anastomoses. We retrospectively compared the intraoperative graft flow characteristics of the end-to-side versus side-to-side anastomoses in the 14 patients. The patient outcomes were also evaluated.
Results
We found that the side-to-side anastomosis reconstruction improved intraoperative flow and reduced pulsatility index in all the 14 patients significantly. The 16 patients who had the distal end side-to-side anastomoses performed directly also exhibited satisfactory intraoperative graft flow. Three-month postoperative outcomes for all the patients were satisfactory.
Conclusions
Side-to-side anastomosis at the distal end of sequential vein grafts might be a promising strategy to connect small target coronary arteries to the GSV.
... A recent report demonstrated the usefulness of side-to-side anastomosis using an arterial graft [5]. However, there have been no reports of the distal end anastomosis in a side-to-side fashion using a SVG. ...
Although the Saphenous Vein Graft (SVG) is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. To overcome such a drawback of the standard end-to-side SVG anastomosis, we introduce a novel side-to-side anastomosis with distal end clipping of the SVG in coronary artery bypass grafting. The long-term outcome of Coronary Artery Bypass Grafting (CABG) depends predominantly on graft patency. Although an arterial graft is preferably used to improve long-term graft patency, a Saphenous Vein Graft (SVG) is also still widely used as a second bypass graft.
The reported SVG patency ranging from 25% to >50% within 10 years was inferior to that of an arterial graft, despite considerable efforts to prevent SVG failure. Although the SVG is commonly grafted to the coronary artery with an end-to-side anastomotic technique, there is often a significant mismatch between the diameters of the SVG and the coronary artery, which may cause SVG failure. Moreover, the end-to-side anastomotic configuration has been reported to have an adverse effect on local hemodynamics, resulting in intimal hyperplasia in the long-term. The intimal hyperplasia, which is a major cause of late graft failure, has been shown to occur predominantly at the toe, heel, and bed of the host coronary artery around the distal anastomosis
Introduction
The distal end anastomosis is critical to the entire sequential grafts in coronary artery bypass grafting (CABG), but caliber mismatch diminishes the quality of the anastomosis. We aimed to introduce a modified distal end side-to-side (deSTS) anastomosis to handle the size mismatch and compared with classic distal end end-to-side (deETS) anastomosis.
Methods
From January 2014 to December 2018, 185 patients who underwent off-pump CABG with size mismatched sequential vein grafts (≥3.5 mm) and target coronaries (1.0–1.5 mm) at the distal end anastomoses were included. We retrospectively reviewed the data of the patients, perioperative and follow-up outcomes were analyzed.
Results
The deSTS group ( n = 67) showed higher anastomotic flow (19.8 ± 8.0 vs 14.9±6.8 mL/min; p < 0.001) and lower pulsatility index (2.7 ± 0.8 vs 3.2 ± 1.0; p = 0.001) than the deETS group ( n = 118). Higher incidence of in-hospital myocardial infarction (MI) was found in the deETS group but without significant difference (9.0% vs. 15.3%; p = 0.220). Kaplan-Meier analysis illustrated a relatively lower MI and major adverse cardiovascular and cerebrovascular events (MACCE) incidence in the deSTS group, and the deSTS group was associated with a reduction in long-term death, MI and MACCE in the adjusted Cox regression model. In addition, relatively higher graft patency was found in the deSTS group.
Conclusions
The deSTS anastomosis showed superiority in solving size mismatch in sequential CABG, including better intraoperative flow dynamics, ideal long-term graft patency and reduced the incidence of perioperative and follow-up adverse events especially in MI.
Background:
Intimal hyperplasia (IH) is a major cause of graft failure. Hemodynamic factors such as stagnation and disturbed blood flow are involved in IH formation. The aim of this study is to perform a comparative analysis of distal-end side-to-side (deSTS) and end-to-side (ETS) anastomoses using computational fluid dynamics (CFD) after validating the results via particle image velocimetry (PIV).Methods and Results:We investigated the characteristics of our target flow fields using CFD under steady and pulsatile flows. CFD via PIV under steady flow in a 10-times-actual-size model was validated. The CFD analysis revealed a recirculation zone in the heel region in the deSTS and ETS anastomoses and at the distal end of the graft, and just distal to the toe of the host artery in the deSTS anastomoses. The recirculation zone sizes changed with the phase shift. We found regions of low wall shear stress and high oscillating shear index in the same areas. The PIV and CFD results were similar.
Conclusions:
It was demonstrated that the hemodynamic characteristics of CFD and PIV is the difference between the deSTS and ETS anastomoses; that is, the deSTS flow peripheral to the distal end of the graft, at the distal end and just distal to the toe of the host artery is involved in the IH formation.
Regarding to coronary artery bypass grafting (CABG), the end-to-side anastomosis (ESA) has been performed as a gold standard. Recently, the effectiveness of the distal side-to-side anastomosis (SSA) in CABG using internal mammary artery has been reported. The benefit of SSA comparing to ESA also has been disclosed by computing simulation. However, use of SSA by venous conduit for individual CABG has not been reported. In this study, we investigated feasibility of SSA. From January 2013 to October 2014, we conducted 114 CABGs. There were 92 venous distal anastomoses without sequential anastomotic site (61 SSA and 31 ESA). The anastomosis was evaluated before discharge and at 1 year after the procedure by angiography or multi-detector row computed tomographic coronary angiography. The median values for time to anastomosis were 13 min in the two group (p = 0.89). There was no revision of anastomosis in both groups. Additional stitches for hemostasis were required significantly less in SSA than ESA (18.0 vs 45.2 %, respectively, p < 0.05). Early angiographic patency; 96.6 % for SSA vs 93.5 % for ESA (p = 0.50), and percentage of good anastomotic figure; 91.2 % for SSA vs 87.1 % for ESA (p = 0.54) were similar in both groups. The angiographic patency at 1 year were 92.9 % for SSA and 81.0 % for ESA (p = 0.16). There was no predictive factor for early and late graft failure. Our study showed feasibility of SSA using venous conduit in individual CABG based on early and mid-term angiographic results. This anastomotic fashion is easy to perform and maybe beneficial in blood flow pattern.
Coronary artery bypass grafting remains the most effective and durable treatment for severe coronary artery disease, but causes significant patient trauma. Efforts to improve the procedure by avoiding cardiopulmonary bypass and/ or by limiting the access are hampered by the increased difficulties of hand suturing the graft connections. Automated anastomotic devices may address these difficulties, provided that current performance standards are matched. For this purpose, the S micro-stapler has been developed. The device has been designed to minimize tissue trauma as well as intraluminal artefact and to provide an easy deployment procedure. To improve reliability, a specific sequence has been built-in, first presenting the tissue using device expansion prior to stapling. Accepted unconventional anastomosis properties are pulsatility non-compliance, inverted vessel wall apposition and a clipped, blind sac, resulting from converting the side-to-side geometry to an end-to-side configuration. Device dimensions are compatible with the majority of internal thoracic artery (ITA) to left anterior descending artery (LAD) anastomoses. Remote actuation minimizes undue movements during deployment, and allows endoscopic application. The preclinical validation included extensive in vitro tests using porcine as well as human tissue, and met preset standards. Chronic tests of the device compared anastomosis patency, remodeling and hemodynamic function to conventionally sutured controls in the off-pump porcine model. The connector rapidly and consistently produced high quality ITA to LAD anastomoses. Thirteen MHz epicardial ultrasound proved effective for intraoperatively assessing anastomosis quality, despite the presence of a metal connector. Evaluation at up to 6 months using angiography, fractional flow reserve measurements and intravascular ultrasound showed 100% patency with an effective vascular remodeling response, resulting in unobstructed anastomoses with excellent hemodynamic function in all cases. Histology showed a stabilized neo-intima on the inside of the anastomoses that was thinner than in the sutured controls. The device’s performance fully met current standards on patency and function. Unconventional aspects like a noncompliant intraluminal ring and a side-to-side to end-to-side converted configuration did not interfere with favorable anastomosis healing. To chart clinical failure modes and to assess the relevance to the S micro-stapler, all publications up to August 2007 on anastomotic devices that included systematic elective angiographic imaging were systematically reviewed. Marked outcome differences between individual devices were found, but could not be correlated to demographic, operative or follow-up differences, anticoagulation regime or device properties like expansion mode, pulsatility non-compliance, implant material or blood exposed non-intimal surface. Significant device and surgery related issues included graft thrombosis, graft kinking and stenosing intimal hyperplasia. Selected devices performed well, and showed that substantial equivalence to the gold standard of tailor-made, hand-sewn anastomoses is possible for automated, intrinsically standardized systems. The design characteristics of the S micro-stapler are well directed at avoiding the observed patency issues, and support expectations of favorable clinical results. In conclusion, reliable anastomotic technology could be the key to mainstream less invasive and port access CABG procedures on the beating heart. The S micro-stapler has the promise to be such a technology, provided that the favorable preclinical results are validated in humans.
