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This photo shows a vessel being loaded onto the C-Port device.

Traditional coronary artery bypass surgery has basically worked the same for the past three decades. The chest is opened while surgeons hand-sew spaghetti-like vessels to bypass a coronary blockage. Technological breakthroughs are pushing CABG procedures closer to the ultimate goal of becoming minimally invasive. The ability to perform heart surgeries “off pump” has already taken bypass surgery into the future. Without the need for a heart-lung machine, bypass surgery has decreased the blood transfusion rate, decreased recovery time and lowered mortality rates for high-risk patients. Now, a new phase of cutting-edge technology is replacing hand-sewn stitches with stainless steel staples.

At the Cardiovascular Surgery Clinic on the Baptist Memorial Hospital campus, cardiothoracic surgeon Dr. Edward Garrett is using Cardica Inc.’s xA distal C-Port® anastomosis system, an automated device that deploys tiny, stainless steel staples to secure a bypass vessel to the coronary artery. This eliminates the need for sutures to be hand-sewn, cutting down surgery and recovery time. In fact, early studies have indicated using an automated stapling device provides increased probability that bypassed vessels will remain free of blockages over time. It can be used on or off-pump and, according to manufacturer information, can produce consistent, reproducible anastomoses, largely independent of surgical technique and skill. An additional benefit is minimal scarring and potential occlusion of the anastomosis by achieving nearly complete alignment of the natural blood lining of the surfaces of the coronary artery and the graft.
In November, Garrett used the C-port system in surgery for the first time.
“We continuously strive to improve patient outcomes using the safest, most technically-advanced and effective devices and procedures when we perform cardiac surgery,” said Garrett. “In this surgical procedure, we used the C-Port xA system, which allows us to quickly and reliably attach blood vessel grafts during bypass surgery, even with the smallest vessels and without stopping the heart. This translates into shorter operating time and reduced recovery time for the patient.”

The 66-year-old patient, undergoing triple-bypass surgery, was a good candidate for using the new device due to her special circumstances – refusal of transfusion due to religion, a pre-existing liver condition, and she had already been turned down for bypass surgery by other surgeons. With no complications, the surgery was a success and the patient is recovering favorably.

With the C-Port system, the anastomosis is completed typically in less than two minutes and requires no additional hand-sewn sutures. With the press of a button, 12 staples — or 24 clips — fire around the vessel. Each clip is very small — only 1/25th of an inch. The artery opens while it is simultaneously connected to the vein in a single, unified procedure.

Using this automated process instead of traditional anastomosis has a distinct advantage; the connection is always the same length and size and allows the vessel to expand and contract with blood flow. Traditional anastomosis uses technically demanding sutures that surround the vessel, and when tied, can sometimes create a “purse string” effect that can create narrowing of the vessel and lessens the blood flow. By eliminating this “purse string” effect, blood flow is improved through the graft from the start, which significantly increases the likelihood the vessels will stay open. The C-Port device can also connect extremely small vessels, as small as 1mm in diameter, which are typically more difficult to bypass, as well as areas of the heart that are difficult to hand-sew during a beating heart procedure.

Beyond faster, more consistent anastomoses, a dependable stapling device, “is the technical tool to make robotic CABG surgery a reality,” said Garrett.
In the future, the device will be instrumental as surgeons use robotics to achieve minimally invasive coronary bypass surgery — using much smaller incisions and without cracking open the chest.

“My interest has been in expanding the use of the robot,” Garrett said, explaining how he saw the C-port system as a necessary tool in evolving bypass surgery to that next level. “We will continue to use it in selected open cases and eventually in robotic cases, starting with single vessel bypasses and progressing to more complex (bypasses).”

While patency findings presented to the American Heart Association scientific sessions in 2007 show the stapling device to provide superior results to traditional suturing (24 of 25 grafts remained open after 90 days), it’s too early to replace the gold standard.

“It looks great at one year,” maintained Garrett, “but we want our bypasses to last 10 to 20 years.”

Hopefully, he added, the standard for coronary bypass surgery will become minimally invasive, which will provide a better outcome than using stents. Bypass surgery is already a longer-lasting solution, but patients often opt for stents to avoid open heart surgery. If the need to open the chest for bypass surgery can be eliminated, Garrett said, patients are likely to choose the more durable procedure.



February 2008

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