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Ann Thorac Surg 2004;78:1831-1833
© 2004 The Society of Thoracic Surgeons

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Case report

Severe Stenosis of Anastomoses by Using the Symmetry Aortic Connector System

^a Department of Cardiac Surgery, Málaga, Spain
^b Department of Cardiology, Virgen de la Victoria University Hospital, Málaga, Spain

Accepted for publication July 17, 2003.

^* Address reprint requests to Dr Melero, Departamento de Cirugía Cardíaca, Hospital Universitario Virgen de la Victoria, Campus Universitario Teatinos, Málaga 29010, Spain
makjom{at}teleline.es

	Abstract

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The St. Jude Medical Symmetry Aortic Connector System was developed to create the proximal vein graft anastomoses in coronary artery bypass grafting. We describe three symptomatic patients with severe stenosis of the proximal anastomosis several months after using the Symmetry aortic connector system. Intravascular ultrasound study showed anastomotic neointimal hyperplasia.

	Introduction

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The St. Jude Medical Symmetry Aortic Connector System (SACS) represents an alternative to the conventional hand-sutured anastomoses. This device avoids aortic bite clamping and reduces the need for aortic manipulation. After the initial enthusiasm, several recent reports describing stenosis in the proximal anastomoses have emerged [1–4]. We describe three symptomatic patients with severe stenosis of the proximal anastomoses several months after using the SACS.

	Case Reports

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Between May 2002 and February 2003, we deployed the SACS in 61 patients (mean age, 67.71 ± 8.13 years). As bypass conduits were used, 84 internal thoracic arteries, 3 radial arteries, and a total of 87 vein grafts. Eighty proximal vein graft anastomoses were performed with the SACS (58 gray SACS for veins with external diameters of 4.5 to 5 mm, 20 green SACS for veins with external diameters of 5 to 5.5 mm, and two blue SACS for veins with external diameters of 5.5 to 6 mm). Fifty-eight patients underwent coronary artery bypass grafting (CABG) alone, 8 with cardiopulmonary bypass and 50 off pump. Three patients underwent concomitant aortic valve replacements in addition to CABG. Intraoperative blood flow was measured for all grafts with the Cardiomed Flowmeter (Medi-Stim, Oslo, Norway).

Patient 1
A 78-year-old man had an urgent operation on September 15, 2002, because of unstable angina and stenosis of the left main coronary artery and right coronary artery. Two saphenous vein grafts to the left anterior descending coronary artery and right coronary artery were placed. Two Symmetry Aortic Connector Systems for veins with external diameters of 4.5 to 5 mm (gray colored) were used to perform the proximal anastomoses. Flow measurements were 50 mL/min and 60 mL/min, respectively. The patient was discharged on postoperative day 10 with aspirin. Three months later the patient was readmitted for unstable angina and cardiogenic shock. Cardiac catheterization showed a subtotal stenosis of the proximal anastomosis of the SACS left anterior descending coronary artery venous graft. The vein graft to the right coronary artery was occluded, and the distal coronary was small. An emergent operation was performed on December 8, 2002, placing the left internal thoracic artery to the left anterior descending coronary artery using extracorporeal circulation. The patient was discharged free of angina on postoperative day 8.

Patient 2
An elective off-pump CABG was performed on August 10, 2002 on a 72-year-old man with high-grade angina and poor ejection fraction. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery and a saphenous vein graft to a marginal branch of the circumflex artery performing the proximal anastomosis with a gray SACS (4.5 to 5 mm). Flow measurements were 40 mL/min for the internal thoracic artery and 50 mL/min for the vein graft. The postoperative course was uneventful, and the patient was discharged 5 days after surgical treatment with acetylsalicylic acid (100 mg/d). In January 2003, he had angina pectoris again, and cardiac catheterization showed a concentric and severe stenosis of the proximal anastomosis related to the nickel-titanium connector (Fig 1); the left internal thoracic artery was completely patent and without stenosis. An intravascular ultrasound study demonstrated a significant lumen loss attributable to anastomotic neointimal hyperplasia (Fig 2). The angina was controlled with medical treatment and the patient was discharged with aspirin plus clopidogrel (75 mg/d).

View larger version (192K): [in this window] [in a new window]   Fig 1. Concentric stenosis of the proximal vein graft anastomosis to a marginal branch of the circumflex artery related to the nickel-titanium connector.

View larger version (63K): [in this window] [in a new window]   Fig 2. Intravascular ultrasound study of proximal anastomosis of saphenous vein graft to a marginal branch of circumflex artery. (A) Two centimeters from the anastomosis the ultrasound image of the vein graft showed no luminal loss with the catheter inside. (B) At the joint between the vein and the aorta, where it is possible to visualize several struts of the connector, the neointimal hyperplasia surrounded the catheter producing a significant lumen reduction. (C = catheter; NH = neointimal hyperplasia.)

View larger version (215K): [in this window] [in a new window]   Fig 3. High-grade stenosis of the proximal vein graft anastomosis to the diagonal coronary artery performed with the Symmetry aortic connector system.

	Comment

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We did not find any common risk factor in the 3 patients we reported. Only 1 of the 3 patients was diabetic and none had diffuse vascular disease or aortic wall disease. Our 3 patients had similar clinical features (ie, use of the smallest SCAS, intraoperative satisfactory flows measurements, uneventful postoperative course, anti-aggregative therapy only with acetylsalicylic acid, onset of angina several months after the CABG surgery, and the same pattern of angiographic stenosis [concentric and located over the nitinol connector]). On the basis of these observations, we thought that the SACS could have the same behavior as an intracoronary stent and the same mechanism of stenosis. Also, the intravascular ultrasound study performed in 2 of 3 patients corroborated this theory by demonstrating neointimal hyperplasia over the nitinol connector.

Eckstein and colleagues [7] proposed only acetylsalicylic acid (100 mg/d) as a postoperative anti-aggregative therapy. But if there is a risk of neointimal hyperplasia in the proximal anastomosis when the smallest SACS is used, this anti-aggregative treatment can be modified and clopidogrel can be added.

To know there is an intrinsic factor in the nitinol connector that can produce a failure of the vein graft leads us to interrupt the routine use of the SACS and reserve the device for patients who have a severely calcified ascending aorta. We have started a retrospective study with coronary angiograms and clinical status of our 61 patients.

Although we fully acknowledge the potential benefits of a nontouch vein graft–aorta anastomosis, further investigations are necessary to evaluate the significance of the SACS in the genesis of proximal graft stenosis and to create a new protocol of anti-aggregative therapy.

	References

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1. Hornik L, Tenderich G, Minami K, et al. First experience with the St. Jude Medical, Inc, Symmetry Bypass System (Aortic Connector System). J Thorac Cardiovasc Surg. 2003;125:414–417[Free Full Text]
2. Reuthebuch O, Lachat M, Kadner A, Turina M. Early bypass occlusion in patients with the St. Jude Medical Symmetry connector. J Thorac Cardiovasc Surg. 2003;125:443–444[Free Full Text]
3. Donsky AS, Schussler JM, Donsky MS, Roberts WC, Hamman BL. Thrombotic occlusion of the aortic ostia of saphenous venous grafts early after coronary artery bypass grafting by using the Symmetry aortic connector system. J Thorac Cardiovasc Surg. 2002;124:397–399[Free Full Text]
4. Carrel TP, Eckstein FS, Englberger L, Windecker S, Meier B. Pitfalls and key lessons with the Symmetry proximal anastomotic device in coronary artery bypass surgery. Ann Thorac Surg. 2003;75:1434–1436[Abstract/Free Full Text]
5. Wiklund L, Bugge M, Berglin E. Angiographic results after the use of a sutureless aortic connector for proximal vein graft anastomoses. Ann Thorac Surg. 2002;73:1993–1994[Abstract/Free Full Text]
6. Antona C, Scrofani R, Lemma M, et al. Assessment of an aorto-saphenous vein graft anastomotic device in coronary surgery: clinical experience and early angiographic results. Ann Thorac Surg. 2002;74:2101–2105[Abstract/Free Full Text]
7. Eckstein FS, Bonilla LF, Englberger L, et al. The St. Jude Medical Symmetry aortic connector system for proximal vein graft anastomoses in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2002;123:777–782[Abstract/Free Full Text]

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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): Jose M. Melero Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Melero, J. M. Articles by Alonso, J. Search for Related Content PubMed PubMed Citation Articles by Melero, J. M. Articles by Alonso, J. Related Collections Coronary disease