Evaluatie van een Novel Laser-bijgestaan ​​Coronaire Anastomotische Connector - de Drie-eenheid Clip - in een Varkens Off-pomp bypass Model

The aim of this procedure is to construct a coronary anastomosis on the beating heart by using a laser assisted non occlusive anastomosis connector, the Trinity clip. This is accomplished by first inserting the upper fork of the connector into the distal end of the graft. The second step is to introduce a laser into the connector into laser punch and opening into the graft.

Next, the lower fork of the connector is inserted into the lumen of the unopened, not occluded coronary artery. Then the connector closes and compresses both vessel walls. The final steps are to laser punch an opening into the coronary artery ligate, the distal end of the graft, and non occlusally complete the bypass.

Ultimately, intraoperative measurements are used to assess the initial quality and function of the anastomosis. The implications of this novel technique is to translate the open coronary artery bypass grafting procedure towards a minimally invasive endoscopic setting by simplifying and automating and so facilitating the distal bypass construction on to the heart. The major advantages of this technique is a non occlusive character at which the graft is a opposed onto the coronary artery without opening of the coronary artery or either occluding of the coronary artery.

In a second step, the anastomosis is completed by introduction of the laser catheter, which exci part of the coronary artery wall, and so opens the anastomosis. This simplifies and makes it potentially applicable for endoscopic or minimally invasive coronary bypass surgery. After preparing the pig for surgery, open the thorax.

Th a sternotomy by hand, bluntly dissect the pericardium of the sternum. Then soro split the sternum between the xiphoid process and the manubrium. Now harvest the internal thoracic artery from the second rib to the diaphragm.

In this case, the left ITA is harvested partially heparinized clip and dissect the ITA at the distal site using it tissue stabilizer immobilize and present the target coronary artery. This artery should have a diameter between 1.6 and 1.9 millimeters. Dissect the target site, remove the loose perial tissue and cover the coronary with papine soaked gauze.

Next, prepare the permanent ligation of the native coronary artery at two to three centimeters proximal to the anastomosis. Use extensive lateral dissection so that a hemog clip will completely ligate the coronary artery. Now dissect the target area of the ITA two to three centimeters proximal to the distal free end.

Remove the perial tissue and measure the caliber of the site. It should have an outer diameter of two to four millimeters. Proceed with constructing the anastomosis using the trinity clip.

Begin by mounting the trinity clip. First, open the upper fork of the connector with the aneurysm clip apply. Insert the opened upper fork into the lumen of the perfused graft with a distal approach.

Ensure that the fork is intraluminal. And then release the applicator. Next, occlude the ITA proximally with a temporary, a traumatic bulldog clip.

Connect a tube from the catheter to a vacuum pump. Put on protective eyewear and introduce the laser catheter intravascularly through the distal free end of the graft into the connector. Fix the catheter in position using a fixation clip.

Now initiate vacuum suction through the catheter onto the graft. Then activate the laser and subsequently, immediately release the vacuum. Visually inspect the arterial wall.

The laser should have laser punched the graft resulting in an anastomotic orifice. The arterial wall should be fully excised. Now, remove the flap of tissue made from the laser punch, which is attached to the vacuum channel of the catheter.

Do not however, remove the catheter. The next step is to make a non occlusive connection of the graft site to the recipient coronary site. Begin by opening the lower fork of the trinity clip connector with a vasco applicator.

Then insert the fork into the lumen of the perfused coronary artery in the distal orientation. Ensure that the full length of the fork is intraluminal and release the applicator. Now proceed with the laser punch arti otomy.

The laser will only successfully laser punch the vessel wall if there's full direct circumferential laser tissue contact. The most critical step of the anastomosis construction, therefore is the correct position of the connector and the laser catheter onto the vessel wall of the graft and the coronary artery. These steps have to be trained on X FIFO models to minimize the learning curve, Initiate vacuum suction on the coronary wall.

Then under form native coronary flow without secluding the coronary laser, punch the coronary wall. Here lasering. Do not apply any force onto the catheter.

In doing this now remove the fixation clip with an aneurysm clip applicator and retract the catheter occlude the distal end of the graft using a temporary clip such as a bulldog clip. In the meantime, have an assistant check if the laser punched flap is attached to the vacuum channel and stop the suction. Place a temporary atraumatic ligation clip at the proximal native LAD and immediately remove the amatic temporary bulldog clip of the proximal ITA to allow graft flow.

The bypass is now functional. If the flap retrieval was successful, proceed by permanently ligating the distal end of the graft with a hemog clip. After performing the anastomosis ligate the coronary artery permanently approximately with three medium sized hemoc clips.

Ensure that no side branches are occluded and that the ligation is completely occlusive. Preventing competitive flow. The graft flow can be adjusted using temporary atraumatic ligation clips at the coronary artery proximal to the anastomosis while adjusting.

Maintain a normal mean arterial blood pressure and keep the heart in a physiological position. A low flow bypass entails a distal ligation and a high flow bypass is achieved using a more proximal ligation, covering the anastomosis with a pericardial patch placed mediastinal and or pleural drains and close the surgical site using standard techniques. Postoperative care details are provided in the text protocol as are details on O-C-T-F-F-R-C-F-R histological analysis and SEM analysis.

During the surgery, transit time flow measurements can be taken by placing a probe on a skeletonized segment of the distal graft using aqueous gel to obtain mean flow flow curves, diastolic filling percentage and the pulsatility index determine the peak hyperemic flow response when the mean arterial pressure is 90 millimeters of mercury. Clamp the graft for 30 seconds and then record the peak hyperemic flow. Calculate the coronary peak hyperemic flow response by the mean peak graft flow divided by the mean baseline flow at 90 millimeters of mercury.

Another option is a standard intraoperative coronary angiography. Introduce a catheter through the iliac artery to visualize the bypass and grade the patency according to the FITZGIBBON criteria. In a small pilot study, three liter to LAD ans were constructed with the connector in the PO sign op cab model.

With a five hour follow-up, the operative data shows that the procedure was quite feasible. There were normal graft flow curves with a pi below five and a predominant diastolic graft filling of 80%or suggestive of a patent coronary graft. Macroscopic inspection at five hours demonstrated patent anastomosis without intraluminal thrombus formation By five weeks, there was complete remodeling and a fully patent anastomosis.

The laser edge was completely covered by a tissue layer without narrowing the anastomotic orifice using histology streamlining neointimal coverage of the initially intraluminal exposed forks of the connector was visible under higher magnification. Compression of the arterial wall was seen without adverse remodel like erosion, laxation, or pseudo aneurysm formation. After watching this video, you should have a good understanding of how to construct an off pump coronary artery bypass by using a Trinity clip in a PORs model and to assess its function and equality.