Distal end side-to-side anastomoses of sequential vein graft to small target coronary arteries improve intraoperative graft flow
- Haitao Li†1,
- Baodong Xie†2,
- Chengxiong Gu1,
- Mingxin Gao1,
- Fan Zhang1,
- Jiayang Wang1,
- Longsheng Dai1 and
- Yang Yu1Email author
© Li et al.; licensee BioMed Central Ltd. 2014
Received: 25 January 2014
Accepted: 29 April 2014
Published: 9 May 2014
End-to-side anastomoses to connect the distal end of the great saphenous vein (GSV) to small target coronary arteries are commonly performed in sequential coronary artery bypass grafting (CABG). However, the oversize diameter ratio between the GSV and small target vessels at end-to-side anastomoses might induce adverse hemodynamic condition. The purpose of this study was to describe a distal end side-to-side anastomosis technique and retrospectively compare the effect of distal end side-to-side versus end-to-side anastomosis on graft flow characteristics.
We performed side-to-side anastomoses to connect the distal end of the GSV to small target vessels on 30 patients undergoing off-pump sequential CABG in our hospital between October 2012 and July 2013. Among the 30 patients, end-to-side anastomoses at the distal end of the GSV were initially performed on 14 patients; however, due to poor graft flow, those anastomoses were revised into side-to-side anastomoses. We retrospectively compared the intraoperative graft flow characteristics of the end-to-side versus side-to-side anastomoses in the 14 patients. The patient outcomes were also evaluated.
We found that the side-to-side anastomosis reconstruction improved intraoperative flow and reduced pulsatility index in all the 14 patients significantly. The 16 patients who had the distal end side-to-side anastomoses performed directly also exhibited satisfactory intraoperative graft flow. Three-month postoperative outcomes for all the patients were satisfactory.
Side-to-side anastomosis at the distal end of sequential vein grafts might be a promising strategy to connect small target coronary arteries to the GSV.
KeywordsCoronary artery bypass grafts venous graft off-pump surgery
An important technical challenge for a cardiac surgeon is to perform high quality anastomoses to small target vessels in coronary artery bypass grafting (CABG). In many Chinese patients, the target coronary arteries available for grafting are small due to either lesion accumulation or intrinsic vessel characteristics. In sequential CABG, an end-to-side anastomosis is usually performed to connect the distal end of the graft and a target coronary artery. However, the diameters of grafts and target vessels are frequently unmatched. Spivack et al. reported that the mean diameter of the great saphenous vein (GSV), which is commonly used for sequential CABG, is between 2.3 mm to 4.4 mm ; while the average diameter of small target coronary arteries of Chinese patients is usually 1 mm. Graft-host diameter ratio has been shown to influence distal anastomotic hemodynamics and consequently graft patency [2–4]. Although large graft-host diameter ratio has been shown to have better hemodynamic performance than smaller ones under end-to-side anastomoses , the oversize diameter ratio between the GSV and small target coronary arteries might induce adverse hemodynamics condition and compromise graft patency. Side-to-side anastomoses, which have been shown to produce favorable hemodynamic flow patterns as compared to end-to-side anastomoses [6–12], might be an option for connecting the distal end of the GSV to small target vessels. The purpose of this study was to introduce a technique of distal end side-to-side anastomosis and compare the effect of side-to-side versus end-to-side anastomosis on intraoperative graft flow characteristics in sequential CABG.
Number of patient
68 ± 3.6 (63–73)
Number of diabetes
Number of hypertension
New York Heart Association Function Classification
All operations were performed through median sternotomy. The GSV was used for sequential grafting in operations. The estimated diameter of the target coronary arteries to be connected to the distal end of the GSV, either the posterior descending artery (PDA) or the posterior left ventricular branch (PLV), was approximately 1 mm in all the patients. The proximal anastomoses were first completed using a partial occlusion clamp and polypropylene 6–0 sutures. Side-to-side anastomoses were performed with a diamond configuration for the middle anastomoses in the sequential grafts. Initially, in 14 patients the distal end anastomoses were revised using side-to-side anastomosis technique after end-to-side anastomoses had shown unfavorable intraoperative graft flow characteristics. Based on the significant improvement of graft flow after the side-to-side anastomotic reconstruction in the 14 patients, an additional 16 patients with small target coronary arteries had distal end side-to-side anastomoses performed.
Transit time flow measurement
Flow parameters including graft blood flow (BF) and pulsatility index (PI) were measured intra-operatively using a transit time flow meter (VeriQ, Medistim Inc, Oslo, Norway) after all anastomoses were completed. The measurement was performed twice for each graft. One measurement was performed by placing the flow probe at 2 cm distal to the aortic anastomosis, and the second measurement was performed by placing the flow probe at 2 cm proximal to the distal end anastomosis of a graft. During the operation, coronary dilators were discontinued. Intraoperative graft flow and PI were measured when blood pressure became stable.
MB isoenzyme of serum creatine kinase (CK-MB) measurement
Serial samples of blood, approximately 5 ml each, were drawn on arrival to the surgical ICU (“post-op”), at 6 h, 24 h, and 48 h after surgery. CK-MB level was analyzed using a commercially available kit (Roche Diagnostics, Indianapolis, Indiana). The conventional threshold of this assay for the diagnosis of myocardial necrosis at our hospital is 6.9 ng/ml. The assay was performed on an Elecsys 1010 platform (Roche Diagnostics, Indianapolis, Indiana).
All the patients came back to follow-up visit three months after the operation. During the follow-up, the cardiac function of the patients was evaluated by electrocardiography and echocardiography.
Data were presented as mean ± standard deviation and analyzed using the statistical analyzing software SPSS (SPSS Inc, Chicago, IL). Pairwise comparison was performed by two-tail Student’s t-test. P < 0.05 was considered statistically significantly different.
Comparison of the graft flow characteristics between end-to-side (ETS) and side-to-side (STS) anastomoses at the distal end of the GSV
Distal end anastomosis (ml/min) ETS/STS
Aortic anastomosis (ml/min) ETS/STS
Distal end anastomosis ETS/STS
Aortic anastomosis ETS/STS
Mean ± SD
5.00 ± 2.63/20.71 ± 8.60*
46.21 ± 11.10/67.93 ± 16.68*
11.31 ± 3.30/2.19 ± 1.01*
3.78 ± 0.93/2.98 ± 0.62#
All the patients came back to follow-up visit three months after the operation. None of the patients experienced any new episode of angina since the operation. Electrocardiography during the follow-up showed significant improvement of myocardial revascularization. Echocardiography during the follow-up revealed that the mean left ventricular ejection fraction (LVEF) was significantly higher than that prior to the operation (55.23 ± 4.99% vs. 51.00 ± 1.19%, P < 0.0001), and the mean left ventricular end-diastolic diameter (LVEDD) was significantly reduced compared with that prior to the operation (52.30 ± 5.69 mm vs. 54.90 ± 5.99 mm, P < 0.05), suggesting that patient heart function was improved significantly.
Side-to-side anastomoses have been described to connect the left internal mammary artery (LIMA) to target coronary vessels for the purpose of reducing surgical damage on LIMA . Song et al. also introduced a technique of side-to-side anastomosis with just ten proportional stitches by hand for artery grafts . In vein sequential grafting, side-to-side anastomoses are usually performed for the middle anastomoses . In this study, to address the issue that oversize graft-host diameter ratio at end-to-side anastomoses might induce adverse hemodynamic condition and reduce graft patency; we applied a side-to-side anastomosis technique to connect the distal end of the GSV to small target arteries in sequential CABG. We retrospectively compared the intraoperative graft flow parameters of patients who had distal end side-to-side anastomotic reconstruction and found that the reconstruction improved graft flow remarkably as compared to the end-to-side anastomoses. The comparison in this study was performed on data collected from the same patients. End-to-side anastomoses were initially performed on the 14 patients. Due to poor graft flow at the distal end, we revised the problematic distal end anastomoses into side-to-side anastomoses, resulting in significant improvement of intraoperative graft flow. We believe that the reason for the initial poor graft flow are not technical errors, instead are associated with unfavorable hemodynamic characteristics at the end-to-side anastomotic site.
Anastomotic geometry has been shown to have substantial effects on the hemodynamics near anastomotic areas. It is believed that small areas of low wall shear stress (WSS) and very few areas of high WSS gradient in the graft indicate a beneficial hemodynamic pattern for optimal graft flow [7–9]. In an end-to-side anastomosis, the vortex flow at the anastomotic heel produces large area of low WSS and high WSS gradient in the graft . This type of hemodynamic pattern impedes graft flow. Multiple reports have suggested that the hemodynamic pattern associated with side-to-side anastomoses might be more favorable for graft patency compared to that of end-to-side anastomoses. Frauenfelder et al. used computational fluid dynamics to simulate pulsatile blood flow in venous grafts based on patient angiography datasets and found that flow stagnation zone exists in end-to-side anastomoses but is absent in side-to-side anastomoses . Sankaranarayanan et al. analyzed the hemodynamic patterns of different anastomotic configuration by computational fluidic dynamics and found that side-to-side anastomoses have smoother blood flow and smaller spatial gradients of WSS than end-to-side anastomosis . Thus, the improved graft flow dynamics we observed likely results from a smoother blood flow pattern at the reconstructed side-to-side anastomoses as compared to a vortex flow pattern at the initial end-to-side anastomoses.
In our study, the diameter ratio between the GSV and the small target coronary arteries was approximately 4:1 in the 30 patients. Graft-host diameter ratio can influence graft hemodynamics at end-to-side anastomoses substantially [2–4]. In a computational simulation model of CABG, Qiao et al. reported that large graft-host diameter ratio (1.46) produces better hemodynamics than equal or small (0.8) ratio when the diameter of a target vessel is assumed to be 2.5 mm . We believe that the beneficial effects of large diameter ratio described in the report are based on the assumption that the target vessels have normal size, and the beneficial effects are limited within certain range of the diameter ratio. As the diameter ratio increases, other factors such as graft transfiguration might induce adverse effects on hemodynamics significantly, leading to an unfavorable flow patter for graft patency. In our study, the graft-host diameter ratio was approximately 4:1. Our data show that end-to-side anastomoses with such oversize diameter ratio resulted in unsatisfactory intraoperative graft flow parameters that required prompt revision, and the side-to-side anastomosis reconstruction markedly improved graft flow and PI.
The patient 3-month follow-up examination showed improved cardiac function, suggesting that patient outcomes of this technique are satisfactory. Kieser et al. conducted a study of long-term follow-up of sequential CABG and found that the patency rate of side-to-side anastomoses is much higher than that of end-to-side anastomoses . To assess the long-term patient outcomes of our distal end side-to-side anastomosis technique, we need to include a control group of patients receiving end-to-side anastomoses at the distal end of sequential grafts. However, in the present study, we had to revise the problematic distal end-to-side anastomoses, which produced unsatisfactory graft flow parameters, into the distal side-to-side anastomoses. Therefore, we were not able to include such control group in this study. The comparison based on the data collected from the same patients suggests that side-to-side anastomoses at the distal end of sequential vein grafts might produce a hemodynamic pattern favorable for long-term graft patency, indicating that distal end side-to-side anastomoses might be a superior anastomotic configuration than end-to-side anastomoses in general. We are now using animal models to compare the long-term graft patency of end-to-side versus side-to-side anastomosis at the distal end of grafts.
The CK-MB levels in our patients significantly dropped 48 hours after the operation, indicating the absence of serious complication associated with the surgical procedure. In this study, we were unable to directly compare CK-MB levels in patients with end-to-side anastomosis versus side-to-side anastomosis due to the absence of a control group with end-to-side anastomosis. However, according to our experience, the average CK-MB levels on arrival to the surgical ICU and 48 hours post-operation in patients undergoing routine CABG in our department are not significantly different from the CK-MB levels described in this report, suggesting that the distal end side-to-side anastomosis procedure do not appear to cause more postoperative complications compared to standard CABG procedure.
In this study, we describe a technique of distal end side-to-side anastomosis in sequential CABG. Our results show that distal end side-to-side anastomoses to small target arteries can improve intraoperative graft flow markedly. Our results indicate that side-to-side anastomosis might be a promising strategy when it is necessary to connect the distal end of GSV to small target arteries in sequential CABG.
HL and BX carried out the study and prepared the draft. CG performed the surgery. MG and FZ participated in data collection and analysis. JW and LD prepared the figure. YY conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
We thank Dr. Jacob Bergsland (UKC Tuzla Interventional Center, National Hospital Oslo Norway) for his insightful comments. This work was supported by the National Natural Science Foundation of China (No. 81170191) and the Beijing NOVA Program (No. 2008B61).
- Spivack DE, Kelly P, Gaughan JP, van Bemmelen PS: Mapping of superficial extremity veins: normal diameters and trends in a vascular patient-population. Ultrasound Med Biol. 2012, 38: 190-194. 10.1016/j.ultrasmedbio.2011.11.008.PubMedView Article
- Longest PW, Kleinstreuer C: Particle-hemodynamics modeling of the distal end-to-side femoral bypass: effects of graft caliber and graft-end cut. Med Eng Phys. 2003, 25: 843-58. 10.1016/S1350-4533(03)00124-3.PubMedView Article
- Ghista DN, Kabinejadian F: Coronary artery bypass grafting hemodynamics and anastomosis design: a biomedical engineering review. Bio Medical Engineering On Line. 2013, 12: 129-
- Keynton RS1, Evancho MM, Sims RL, Rittgers SE: The effect of graft caliber upon wall shear within in vivo distal vascular anastomoses. J Biomech Eng. 1999, 121: 79-88. 10.1115/1.2798047.PubMedView Article
- Qiao A, Liu Y: Influence of graft-host diameter ratio on the hemodynamics of CABG. Biomed Mater Eng. 2006, 16: 189-201.PubMed
- Sewell WH: Improved coronary vein graft patency rates with side-to-side anastomoses. Ann Thorac Surg. 1974, 17: 538-544. 10.1016/S0003-4975(10)65695-0.PubMedView Article
- Bonert M, Myers JG, Fremes S, WILLIAMS J, ETHIER CR: A Numerical Study of Blood Flow in Coronary Artery Bypass Graft Side-to-Side Anastomoses. Ann Biomed Eng. 2002, 30: 599-611.PubMedView Article
- Kabinejadian F, Chua LP, Ghista DN, Sankaranarayanan M, Tan YS: A novel coronary artery bypass graft design of sequential anastomoses. Ann Biomed Eng. 2010, 38: 3135-3150. 10.1007/s10439-010-0068-5.PubMedView Article
- Kabinejadian F, Ghista DN: Compliant model of a coupled sequential coronary arterial bypass graft: effects of vessel wall elasticity and non-Newtonian rheology on blood flow regime and hemodynamic parameters distribution. Med Eng Phys. 2012, 34: 860-872. 10.1016/j.medengphy.2011.10.001.PubMedView Article
- Frauenfelder T, Boutsianis E, Schertler T, Husmann L, Leschka S, Poulikakos D, Marincek B, Alkadhi H: Flow and wall shear stress in end-to-side and side-to-side anastomosis of venous coronary artery bypass grafts. BioMed Eng OnLine. 2007, 6: 35-48. 10.1186/1475-925X-6-35.PubMedPubMed CentralView Article
- Sankaranarayanan M, Ghista DN, Chua LP, Tan YS, Sundaravadivelu K, Kassab GS: Blood flow in an out-of-plane aortag-left coronary sequential bypass graft. Computational Cardiovascular Mechanics: Modeling and Applications in Heart Failure. Edited by: Guccione JM, Kassab GS, Ratcliffe M. 2010, New York: Springer-Verlag, 277-297.View Article
- Nabuchi A, Kurata A, Tsukuda K, Tajima H, Kim K: Side-to-Side Anastomosis in Off-Pump Coronary Artery Bypass Grafting. Asian Cardiovasc Thorac Ann. 2000, 8: 394-397. 10.1177/021849230000800427.View Article
- Song MH, Tokuda Y, Ito T: Revival of the side-to-side approach for distal coronary anastomosis. J Cardiothorac Surg. 2007, 2: 2-7. 10.1186/1749-8090-2-2.PubMedPubMed CentralView Article
- Kieser TM, FitzGibbon GM, Keon WJ: Sequential coronary bypass grafts. Long-term follow-up. J Thorac Cardiovasc Surg. 1986, 91: 767-772.PubMed
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/14/65/prepub
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