Vascular connector devices increase the availability of minimally invasive cardiac surgery to ischemic heart patients

摘要

In what is believed to be the first Soviet contribution to American medical literature, Pavel Androsov described the first vascular anastomotic device in 1956. After World War II, Androsov favored the use of his device over vascular ligation, citing reasons that would be still valid in our current day [1]. Four years later, the first human coronary artery bypass (CAB) procedure took place, reported by Robert Goetz at Albert Einstein University. Interestingly, this first attempt (Right internal mammary artery to right coronary artery) was done using a tantalum ring anastomotic device with circumferential sutures. In Leningrad in 1964, Vasilii Kolesov performed the first hand-sewn clinical CAB, citing Goetz’ work as a predecessor [2]. Three years later, he performed the first, and for a long time the only, coronary anastomosis using a vascular stapler, and three years later, the patient remained free of symptoms [3].Many anastomotic devices were designed and produced in the 1960’s, but the advent of cardiopulmonary bypass (CPB) and its wide adoption made hand suturing on a motionless heart a more convenient option to surgeons. Vascular connector devices eventually faded away from the interest of surgeons, and hence manufacturers, and for a long time, the well established CAB technique remained – efficient but technically stagnant. In the 1990’s, against the background of significant morbidities associated with the use of CPB and myocardial ischemic arrest, interest in off-pump CAB surgery (OP-CAB) was reawakened. This revival of interest re-established the same circumstances that brought interest to vascular connectors 40 years earlier. Not much later, the development of minimally invasive cardiac surgery - CAB (MICS-CAB) and totally endoscopic CAB (TECAB) made the hand suturing technique even more challenging and excessively time consuming, making connector devices, once again, an attractive option. Although graft failure is probably multi-factorial, technical error still shares a good deal in this failure. Anastomotic connector devices decrease the error in hitting a moving target (OPCAB), as well as facilitate graft anastomoses in a restricted space (MICS-CAB). Other non-technical advantages are displayed as well. Eliminating the need for an aortic cross clamp has been achieved in OPCAB, but the proximal anastomoses still mandated a partial clamp application. This has been reported to consistently increase rates of stroke after CAB surgeries [4,5,6,7]. Connector devices allow performing proximal anastomoses with minimal aortic manipulation, and thus improve neurological outcomes. Also, the supposedly reduced time needed to complete an anastomosis using a connector device would allow for less hemodynamic instability, when grafting posterior vessels off-pump, as well as allow for a shorter clamp time when using CPB and ischemic arrest, and thus would be associated with less morbidity and mortality [8,9]. More than 60 connector devices have been designed and produced by several manufacturers for coronary bypass surgery alone, and due to different outcomes and economic reasons, only a few of them came to fruition [10,11]. A perfect connector device should display a number of geometric, physiological, technical and outcome characteristics, in a cost effective context.These characteristics would ensure patency rates that are at least, and adverse event rates that are at most, equal to standard hand suturing technique. An understanding of how this can be, invites an understanding of how failure happens. Altering flow dynamics and disrupting endothelial continuity may lead to thrombosis, intimal hyperplasia or both. The blood exposed non-intimal surface (BENIS), whether it be the media, adventitia or foreign material (suture, metal, etc) has been directly correlated to thrombosis [11]. This is the reason why two distal connector devices are no longer available; the Graft Connector of Jomed (Jomed Inernational