How to Do It
Sharma’s clamp for sequential coronary artery grafting
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(8) 1007–1009 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315585045 aan.sagepub.com
Ashok Kumar Sharma, Mohammad Salman Siddiqi and Hilal Al Sabti
Abstract Sequential coronary artery grafting is a common procedure. Holding the graft in the correct alignment and orientation in a limited pericardial space and taking a suture at the correct place on the graft is difficult. Graft slippage from the assistant can be distracting to the surgeon, unnecessarily increasing the anastomosis time and also affecting graft patency due to improperly placed sutures. We describe a simple device (Sharma’s clamp) for graft holding and stabilization for sequential bypass grafting in coronary artery bypass surgery.
Keywords Anastomosis, surgical, Coronary artery bypass, Equipment design, Surgical instruments
Introduction Sequential coronary artery bypass grafting (CABG) has been used for coronary revascularization for a very long time. The main advantage over the single graft technique is saving of graft material (particularly in redo cases where sufficient graft length is not available), fewer proximal anastomosis, improved hemodynamics because of more complete revascularization, and better flow due to decreased resistance as a result of multiple anastomoses and shorter operative and ischemic arrest times. This technique is being used increasingly in multivessel coronary artery disease with severe atheromatous ascending aorta where partial clamp application can cause dislodgment of loose plaque material, leading to stroke. Performing sequential grafting is not always easy, it is a delicate and technically challenging job. Choosing the proper site, stabilization, the length of the opening, and accurate stitching, are all very important for proper alignment and hence good flow through the graft, especially in diamond-shaped sequential grafts. Various instruments and techniques have been used to stabilize and correctly secure the graft in the optimum position for side-to-side anastomosis in sequential grafting for CABG. However, most of these devices have inherent limitations of improper holding of the graft, poor graft stabilization, and being bulky. To overcome these limitations, the senior author (AKS) has designed, developed, and used a
simple instrument (Sharma’s clamp) for holding the graft in the correct position, in the correct plane, and with proper stabilization for ease of side-to-side anastomosis in sequential grafting for CABG.
Technique The clamp consists of a metal clip with two nontraumatic prongs. The manufacturer has tested the pressure exerted by the clamp over the tissue, which has a closing force of 50 g. This force is defined as the weight in grams that the clamp exerts at a defined point on the clamp’s jaws, or conversely, the weight in grams needed to open the jaws to a particular width. The routine vascular bulldog instrument exerts a force of 60–90 g. Thus this clamp is safe to use without producing any intimal or tissue injury. There is a rectangular space between the two prongs for graft fixation, stabilization, and proper visualization of the side of the graft (Figure 1). The graft holder rests on a small Ray-Tec
Cardiothoracic Surgery Division, Sultan Qaboos University Hospital, Muscat, Oman Corresponding author: Ashok Kumar Sharma, Cardiothoracic Surgery Division, PO Box 35, Sultan Qaboos University Hospital, Muscat 123, Oman. Email: [email protected]
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
1008
Asian Cardiovascular & Thoracic Annals 23(8)
Figure 1. Sharma’s clamp in different views.
Figure 2. Clamp application on the graft.
gauze (4 4-cm) which provides stabilization and prevents the graft from slipping into the pericardial cavity. There is no need for the assistant to hold the graft holder, and it is placed adjacent to the coronary artery incision (Figure 2). The graft for sequential anastomosis is distended. The proper site for anastomosis on the undersurface is chosen, and the clamp is applied, keeping the site of anastomosis in the middle. The clamp holding the graft is rotated by 90 to expose the site of anastomosis, facing the surgeon directly (Figure 3). Depending on the alignment, a longitudinal,
Figure 3. Incision of the graft with 90-degree rotation of the clamp.
oblique, or diamond-shaped anastomosis is performed by starting the stitching appropriately on the graft incision. Halfway through the anastomosis, the graft is pulled by the parachute technique, the clamp is removed, and the rest of the anastomosis is completed (Figure 4). Thus the clamp simplifies the technique of sequential grafting. The clamp can be used for holding vein, internal mammary artery, radial artery, or any other conduit such as gastroepiploic artery. It works well in both on- and off-pump CABG.
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
Sharma et al.
1009
Figure 4. Start of the anastomosis with clear visualization of both openings.
This side graft holder allows the surgeon to perform side-to-side anastomosis in sequential grafting with ease, in a simple, consistent and reproducible manner. The instrument can be used for end-to-end anastomosis of the graft for graft lengthening by holding the two ends in the prongs. It can also be used for transected nerve repairs by bringing the two ends together. We will soon publish our results with this device once our target number of patients is reached. Presently, we have not patented our device but we are in the process of filing for a patent. Acknowledgement The authors acknowledge the help of Sun Medical Equipment (Oman) in helping to fabricate the instrument.
Discussion Sequential bypass grafting using side-to-side anastomosis is frequently used for CABG. The graft holder (Sharma’s clamp) is a simple instrument that gives excellent atraumatic stabilization and visualization of the side of the graft in the limited pericardial space. Its use prevents unnecessary direct manipulation of graft by instruments, thereby preventing intimal injury. Assistant need is reduced except to use a mist blower to keep the field blood-free. The device is different from that used by Shimamura and Hayashi1,2 because their device has a handle to hold it, while ours is handsfree; both of the assistant’s hands are free to assist the surgeon. Opening of the graft is always under vision, allowing correct and precise stitch placement to prevent graft stenosis. The holder also prevents graft twisting once it is fixed to it.
Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Shimamura Y and Hayashi I. A novel side graft holder for coronary artery bypass grafting. Ann Thorac Surg 2009; 87: 1628–1629. 2. Shimamura Y and Hayashi I. Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery. Interact Cardiovasc Thorac Surg 2009; 9: 939–942.
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
Sharma’s clamp for sequential coronary artery grafting
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(8) 1007–1009 ß The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492315585045 aan.sagepub.com
Ashok Kumar Sharma, Mohammad Salman Siddiqi and Hilal Al Sabti
Abstract Sequential coronary artery grafting is a common procedure. Holding the graft in the correct alignment and orientation in a limited pericardial space and taking a suture at the correct place on the graft is difficult. Graft slippage from the assistant can be distracting to the surgeon, unnecessarily increasing the anastomosis time and also affecting graft patency due to improperly placed sutures. We describe a simple device (Sharma’s clamp) for graft holding and stabilization for sequential bypass grafting in coronary artery bypass surgery.
Keywords Anastomosis, surgical, Coronary artery bypass, Equipment design, Surgical instruments
Introduction Sequential coronary artery bypass grafting (CABG) has been used for coronary revascularization for a very long time. The main advantage over the single graft technique is saving of graft material (particularly in redo cases where sufficient graft length is not available), fewer proximal anastomosis, improved hemodynamics because of more complete revascularization, and better flow due to decreased resistance as a result of multiple anastomoses and shorter operative and ischemic arrest times. This technique is being used increasingly in multivessel coronary artery disease with severe atheromatous ascending aorta where partial clamp application can cause dislodgment of loose plaque material, leading to stroke. Performing sequential grafting is not always easy, it is a delicate and technically challenging job. Choosing the proper site, stabilization, the length of the opening, and accurate stitching, are all very important for proper alignment and hence good flow through the graft, especially in diamond-shaped sequential grafts. Various instruments and techniques have been used to stabilize and correctly secure the graft in the optimum position for side-to-side anastomosis in sequential grafting for CABG. However, most of these devices have inherent limitations of improper holding of the graft, poor graft stabilization, and being bulky. To overcome these limitations, the senior author (AKS) has designed, developed, and used a
simple instrument (Sharma’s clamp) for holding the graft in the correct position, in the correct plane, and with proper stabilization for ease of side-to-side anastomosis in sequential grafting for CABG.
Technique The clamp consists of a metal clip with two nontraumatic prongs. The manufacturer has tested the pressure exerted by the clamp over the tissue, which has a closing force of 50 g. This force is defined as the weight in grams that the clamp exerts at a defined point on the clamp’s jaws, or conversely, the weight in grams needed to open the jaws to a particular width. The routine vascular bulldog instrument exerts a force of 60–90 g. Thus this clamp is safe to use without producing any intimal or tissue injury. There is a rectangular space between the two prongs for graft fixation, stabilization, and proper visualization of the side of the graft (Figure 1). The graft holder rests on a small Ray-Tec
Cardiothoracic Surgery Division, Sultan Qaboos University Hospital, Muscat, Oman Corresponding author: Ashok Kumar Sharma, Cardiothoracic Surgery Division, PO Box 35, Sultan Qaboos University Hospital, Muscat 123, Oman. Email: [email protected]
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
1008
Asian Cardiovascular & Thoracic Annals 23(8)
Figure 1. Sharma’s clamp in different views.
Figure 2. Clamp application on the graft.
gauze (4 4-cm) which provides stabilization and prevents the graft from slipping into the pericardial cavity. There is no need for the assistant to hold the graft holder, and it is placed adjacent to the coronary artery incision (Figure 2). The graft for sequential anastomosis is distended. The proper site for anastomosis on the undersurface is chosen, and the clamp is applied, keeping the site of anastomosis in the middle. The clamp holding the graft is rotated by 90 to expose the site of anastomosis, facing the surgeon directly (Figure 3). Depending on the alignment, a longitudinal,
Figure 3. Incision of the graft with 90-degree rotation of the clamp.
oblique, or diamond-shaped anastomosis is performed by starting the stitching appropriately on the graft incision. Halfway through the anastomosis, the graft is pulled by the parachute technique, the clamp is removed, and the rest of the anastomosis is completed (Figure 4). Thus the clamp simplifies the technique of sequential grafting. The clamp can be used for holding vein, internal mammary artery, radial artery, or any other conduit such as gastroepiploic artery. It works well in both on- and off-pump CABG.
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
Sharma et al.
1009
Figure 4. Start of the anastomosis with clear visualization of both openings.
This side graft holder allows the surgeon to perform side-to-side anastomosis in sequential grafting with ease, in a simple, consistent and reproducible manner. The instrument can be used for end-to-end anastomosis of the graft for graft lengthening by holding the two ends in the prongs. It can also be used for transected nerve repairs by bringing the two ends together. We will soon publish our results with this device once our target number of patients is reached. Presently, we have not patented our device but we are in the process of filing for a patent. Acknowledgement The authors acknowledge the help of Sun Medical Equipment (Oman) in helping to fabricate the instrument.
Discussion Sequential bypass grafting using side-to-side anastomosis is frequently used for CABG. The graft holder (Sharma’s clamp) is a simple instrument that gives excellent atraumatic stabilization and visualization of the side of the graft in the limited pericardial space. Its use prevents unnecessary direct manipulation of graft by instruments, thereby preventing intimal injury. Assistant need is reduced except to use a mist blower to keep the field blood-free. The device is different from that used by Shimamura and Hayashi1,2 because their device has a handle to hold it, while ours is handsfree; both of the assistant’s hands are free to assist the surgeon. Opening of the graft is always under vision, allowing correct and precise stitch placement to prevent graft stenosis. The holder also prevents graft twisting once it is fixed to it.
Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Shimamura Y and Hayashi I. A novel side graft holder for coronary artery bypass grafting. Ann Thorac Surg 2009; 87: 1628–1629. 2. Shimamura Y and Hayashi I. Graft fixation with a side graft holder for sequential and composite graft anastomosis in coronary artery bypass surgery. Interact Cardiovasc Thorac Surg 2009; 9: 939–942.
Downloaded from aan.sagepub.com at University of Otago Library on November 14, 2015
