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A Laser-Assisted Anastomotic Technique: Feasibility on Human Diseased Coronary Arteries. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:116-22. [PMID: 26926763 DOI: 10.1097/imi.0000000000000241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Atherosclerotic disease might hamper the efficacy of the Excimer laser-assisted Trinity Clip anastomotic connector in coronary arteries. Therefore, its efficacy was evaluated on human diseased coronary arteries (study 1). In addition, the acute laser effects onto the coronary wall were assessed (study 2). METHODS Thirty-eight anastomoses were constructed on ex vivo human hearts. Atherosclerosis was histopathologically determined and subsequently related to the success of the technique (ie, connector positioning and laser punching; study 1). In addition, 20 anastomoses were constructed in an ex vivo (porcine, n = 8) and an in vivo [rabbit (n = 9) and porcine (n = 3)] model. Subsequently, the coronary was histologically studied on the presence of laser-induced damage (study 2). RESULTS In 13 of 38 anastomoses (study 1), the connector was malpositioned, 3 because of a severely diseased coronary wall and 10 because of an inner diameter less than the intended target range. The laser-punch success rates on coronary arteries with an early and advanced lesion were 100% (16/16) and 89% (8/9; lesions were located in the inferolateral wall), respectively. In one case, an advanced lesion (ie, fibrocalcified plaque) was located in the superolateral wall and caused a laser-punch failure. No histological signs of laser-induced damage were observed, in case of correct use (study 2). CONCLUSIONS This study demonstrates the feasibility of an anastomotic connector on human diseased coronary arteries and shows that lasering does not induce coronary wall damage. However, careful selection of the coronary, regarding the target inner diameter and disease status, will prevent construction failures. This connector could facilitate less invasive coronary artery bypass grafting.
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Stecher D, Bronkers G, Vink A, Homoet-van der Kraak PH, Helthuis J, Pasterkamp G, Buijsrogge MP. A Laser-Assisted Anastomotic Technique: Feasibility on Human Diseased Coronary Arteries. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- David Stecher
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Aryan Vink
- Department of Pathology, Laboratories and Pharmacy Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Petra H. Homoet-van der Kraak
- Department of Pathology, Laboratories and Pharmacy Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jasper Helthuis
- Department of Neurosurgery, Brain Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gerard Pasterkamp
- Department of Experimental Cardiology, Heart and Lungs Division, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc P. Buijsrogge
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Takami Y, Tajima K, Kato W, Fujii K, Hibino M, Munakata H, Sakai Y. Clinical validation of coronary artery flow through an intracoronary shunt during off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012; 147:259-63. [PMID: 23141031 DOI: 10.1016/j.jtcvs.2012.10.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 09/19/2012] [Accepted: 10/16/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Intracoronary shunts have been developed for a bloodless field and preserved forward flow preventing ischemia during off-pump coronary artery bypass (OPCAB) surgery. However, reports directly measuring the forward flow through the shunt in clinical settings are lacking. METHODS Using a 7.5-MHz Doppler probe, we investigated the coronary flow through a 1.5-mm shunt inserted into the left anterior descending artery (LAD) for anastomosis with the internal thoracic artery during OPCAB in 30 consecutive patients. The following Doppler flow parameters were obtained before and after shunting: peak velocity, mean velocity, time-velocity integral, and flow. RESULTS No patients developed significant electrocardiographic changes and the peak value of postoperative myocardial band of creatine kinase was 17 ± 16 IU/L. All Doppler flow parameters of the LAD decreased significantly after shunting; peal velocity: 71.3 ± 34.6 cm/second to 54.5 ± 25.3 cm/second (-24% ± 27%), mean velocity: 33.3 ± 18.3 cm/second to 26.3 ± 14.0 cm/second (-21% ± 23%), and time-velocity integral: 28.7 ± 12.1 cm to 19.0 ± 7.1 cm (-28% ± 14%), and flow: 38.7 ± 16.8 mL/minute to 25.0 ± 9.5 mL/minute (-31% ± 13%) (P < .01). CONCLUSIONS The LAD flow is preserved at least 50% through a 1.5-mm intracoronary shunt, although the flow pattern was attenuated, during OPCAB anastomosis. The Doppler evaluation of the coronary artery flow before and after shunting is useful to justify the protective use of the shunt on myocardial perfusion during OPCAB.
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Affiliation(s)
- Yoshiyuki Takami
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | - Kazuyoshi Tajima
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Wataru Kato
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kei Fujii
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Makoto Hibino
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Hisaaki Munakata
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Yoshimasa Sakai
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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Wimmer-Greinecker G, Bouchot O, Verhoye JP, Perrault LP, Börgermann J, Diegeler A, Van Garsse L, Rastan AJ. Randomized Clinical Trial Comparing a Thermosensitive Polymer (LeGoo) With Conventional Vessel Loops for Temporary Coronary Artery Occlusion During Off-Pump Coronary Artery Bypass Surgery. Ann Thorac Surg 2011; 92:2177-83. [DOI: 10.1016/j.athoracsur.2011.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Revised: 07/04/2011] [Accepted: 07/11/2011] [Indexed: 11/26/2022]
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Prolonged indwelling time of temporary vascular shunts is associated with increased endothelial injury in the porcine mesenteric artery. ACTA ACUST UNITED AC 2011; 70:1464-70. [PMID: 21817984 DOI: 10.1097/ta.0b013e31820c9b4e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Temporary intravascular shunts (TIVS) have been used as a damage control surgery (DCS) adjuncts in superior mesenteric artery (SMA) injuries, both experimentally and clinically. However, no study to date has evaluated the relationship between shunt indwelling time and resultant endothelial cell (EC) injury. We hypothesized that prolonged use of TIVS in SMA injuries would jeopardize EC integrity. METHOD After laparotomy, the SMA was clamped and transected while pigs were hemorrhaged to 40 mm Hg for 30 minutes. A TIVS was inserted between transected ends of the SMA without systemic anticoagulation. Totally, 24 animals were resuscitated and randomized to different shunt indwelling time groups: A, 3 hours; B, 6 hours; C, 9 hours; and D, 12 hours. Patency of shunts was monitored and recorded. Continuous wave Doppler was used as a determinant of adequacy of flow through the shunts. Transmural SMA biopsies from areas of TIVS placement were examined with electron microscopy for histopathologic injury after staining with hematoxylin and eosin and immunofluorescence using a validated histopathologic injury score (minimum-maximum score: 0-4). RESULTS Severity of endothelial injury was observed to be directly related to shunt indwell time. SMA transmural biopsies harvested from group D animals showed the most profound injury, demonstrating extensive EC denudations and marked intimal rupture (injury grade, 3.4 ± 0.2). Sections from group A animals revealed the mildest EC injury (1.3 ± 0.3 vs. group D p < 0.01). No significant difference was detected between group A and B. EC injury grade in group C (2.7 ± 0.6) was higher than that in group B (1.8 ± 0.6) but did not reach statistical significance (p = 0.58). CONCLUSION When possible, vascular reconstruction following use of shunts should include an interposition graft after debridement of the arterial edges having interfaced with the shunt. Finally, to minimize intimal injury to the native vessel, this model suggests that indwell times of shunts should be <9 hours.
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Rastan AJ, Noack T, Subramanian S, Nacar A, Holzhey D, Falk V, Mohr FW. Facilitated anastomosis using a reverse thermo-sensitive polymer for temporary coronary occlusion in off-pump minimally invasive direct coronary artery bypass surgery☆. Interact Cardiovasc Thorac Surg 2010; 11:532-6. [DOI: 10.1510/icvts.2010.233916] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mantovani V, Kennergren C, Bugge M, Sala A, Lönnroth P, Berglin E. Myocardial metabolism assessed by microdialysis: A prospective randomized study in on- and off-pump coronary bypass surgery. Int J Cardiol 2010; 143:302-8. [DOI: 10.1016/j.ijcard.2009.03.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 05/30/2008] [Accepted: 03/04/2009] [Indexed: 11/29/2022]
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Letsou GV, Grunkemeier GL, Salaskar AL, Bavare C, Wu Y, Rampurwala MM. Selective Left Anterior Descending Shunting Provides Effective Off-pump Myocardial Protection. Ann Thorac Surg 2010; 89:24-9. [DOI: 10.1016/j.athoracsur.2009.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Revised: 09/14/2009] [Accepted: 09/15/2009] [Indexed: 10/20/2022]
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Shim JK, Bang SO, Lee JH, Oh YJ, Yoo KJ, Kwak YL. Effect of intracoronary shunt on right ventricular function during off-pump grafting of dominant right coronary artery with poor collateral. J Korean Med Sci 2008; 23:373-7. [PMID: 18583869 PMCID: PMC2526513 DOI: 10.3346/jkms.2008.23.3.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.
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Affiliation(s)
- Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University Health System, Seoul, Korea
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Vural AH, Yalcinkaya S, Türk T, Yümün G, Gül N, Yalcinkaya U, Kaya M, Ozyazicioğlu A. Intracoronary shunt versus bulldog clamp in off-pump bypass surgery. Endothelial trauma: shunt versus clamp. J Surg Res 2008; 150:261-5. [PMID: 18262555 DOI: 10.1016/j.jss.2007.12.774] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Revised: 10/25/2007] [Accepted: 12/06/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND During off-pump coronary bypass grafting, local vascular control of the target vessel and a bloodless field are crucial. The aim of this study is to asses the histopathological outcomes of intracoronary shunts and bulldog clamping on the beating heart in a canine model. METHODS Twelve healthy adult mongrel dogs weighing between 15 to 25 kg were included in the study. Following left thoracotomy, proximal left anterior descending artery segment 1 cm to distal of diagonal branch was marked. Arteriotomy at this site was performed and a shunt was inserted for 10 min in the shunt group. The bulldog clamp was applied 3 cm distal to the mark for 10 min after heparinization in the bulldog group. Thirty days after the procedure, the specimens of left anterior descending artery from both regions were collected and were examined. Vascular damage, presence of intimal hyperplasia, and denudation were noted. RESULTS Only intimal denudation was found significantly higher in the shunt group (P < 0.05). In this group, only one case had grade 0 endothelial damage. In the bulldog group, all cases had endothelial damage of various grades. CONCLUSION The proven advantages of temporary intracoronary shunts are well-known, e.g., preserving the ventricular functions. Despite these advantages, our study revealed an ultimate bad result for an off-pump coronary by pass patient: intimal denudation. We conclude that further studies with a larger number of subjects are needed to decide whether routine shunt insertion into coronary arteries during off-pump coronary bypass surgery is appropriate or not.
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Affiliation(s)
- A Hakan Vural
- Department of Cardiovascular Surgery, Bursa Yüksek Ihtisas Education and Research Hospital, Bursa, Turkey.
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Bottio T, Tarzia V, Gerosa G. Temporary coronary artery occlusion during off-pump surgery and endothelial vessel dysfunction: is it still an unresolved mystery? J Thorac Cardiovasc Surg 2007; 133:1397; author reply 1397-8. [PMID: 17467487 DOI: 10.1016/j.jtcvs.2007.01.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2007] [Accepted: 01/09/2007] [Indexed: 11/17/2022]
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Collison SP, Agarwal A, Trehan N. Controversies in the Use of Intraluminal Shunts During Off-Pump Coronary Artery Bypass Grafting Surgery. Ann Thorac Surg 2006; 82:1559-66. [PMID: 16996987 DOI: 10.1016/j.athoracsur.2006.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2006] [Revised: 05/03/2006] [Accepted: 05/04/2006] [Indexed: 10/24/2022]
Abstract
Technical advances have made the performance of multivessel off-pump coronary artery bypass feasible. Snaring and intraluminal shunts are the techniques used for vascular control. Snaring provides a bloodless surgical field, is usually well tolerated by the patient, and is supported by years of clinical experience. Intraluminal shunts aim to achieve hemostasis at the arteriotomy site and to allow antegrade flow to provide myocardial protection. There are unresolved issues regarding whether shunts have a clinical benefit, do provide adequate flow to provide myocardial protection, and whether they cause significant endothelial damage. In this article, we have reviewed the literature to lend perspective to these issues.
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Dygert JH, Thatte HS, Kumbhani DJ, Najjar SF, Treanor PR, Khuri SF. Intracoronary Shunt-Induced Endothelial Cell Damage in Porcine Heart. J Surg Res 2006; 131:168-74. [PMID: 16412472 DOI: 10.1016/j.jss.2005.10.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2005] [Revised: 10/21/2005] [Accepted: 10/24/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND Injury to and dysfunction of the endothelium can compromise the patency of coronary arteries and lead to impaired perfusion of the heart. Such injury can occur after the application of an intravascular shunt and/or a snare to a coronary artery during bypass surgery. In this study, multiphoton microscopy was used to assess the integrity of endothelium in porcine coronary arteries subjected to shunting and snaring during off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS In open chest porcine, the left anterior descending artery was manipulated in different regions using snare and shunt to simulate OPCAB. Sections of left anterior descending artery were labeled with fluorescent dyes to evaluate the viability of the endothelium. The structural integrity of the endothelium was evaluated by calcein- and ethidium homodimer-mediated fluorescence. Endothelial functional viability was assessed by measuring cellular esterase activity, calcium mobilization, and endothelial nitric oxide synthase-mediated generation of nitric oxide using fluorescence dyes and multiphoton microscopy. RESULTS Substantial endothelial damage was observed in shunted region of the coronary arteries. In contrast, endothelium remained structurally viable in regions that were snared, similar to control regions of the coronary arteries that were not manipulated. Esterase activity, calcium mobilization, and nitric oxide generation was greater in the control and snared regions of the coronary arteries in comparison to the shunted region. CONCLUSIONS The use of intracoronary shunts led to structural damage and attenuation of endothelial function in porcine coronary arteries, whereas snared vessels maintained their viability and integrity, similar to the control sections. The routine use of shunts in OPCABG may lead to endothelial damage and possibly to long-term graft failure.
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Affiliation(s)
- James H Dygert
- Department of Surgery, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02132, USA
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