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    • Coronary artery bypass grafting is the most commonly performed cardiac surgery in the world and one of the essential therapeutic alternatives for coronary artery disease1. This surgical approach uses a graft to create a bridge between the aorta or one of its branches and the coronary arteries, and aims to re-establish normal perfusion flow downstream of occlusive or stenosing lesions. This technical procedure will require constant vigilance from the surgeon, and aims to ensure the best possible haemostasis while reducing trauma to the blood vessels and cardiac structures. The equipment used will be important for reducing the risk of intra- and post-operative complications, thanks to its properties adapted to the specific use during surgery.

     

    Atraumatic haemostasis with surgical titanium ligation clips and applicators

    During the heart opening and graft harvesting phases, good haemostasis of the vessels, grafts and collateral branches will be a decisive factor in limiting the risk of haemorrhaging and guaranteeing the best visibility for the surgeon. The use of titanium haemostatic clips, Clip 9 Vitalitec® or Clip SLS Vitalitec®, will ensure effective haemostasis while respecting vessel tissue. They are composed of 100% titanium, which makes them biologically inert and radio opaque. The clips must be of a suitable size and have non-slip properties adapted to the specific use, to ensure good stability and sufficient resistance to blood pressure. The atraumatic features of these titanium surgical clips means that the integrity of the grafts can be preserved as far as possible. Clip applicators are used for ease of use and precision when applying the clips to avoid asymmetric overlap of the clip arms, which could be a source of tissue injury and therefore haematomas and vessel dissection. Working with a range of adapted surgical clips will provide the surgeon with good operative manoeuvrability throughout the procedure and confidence in the haemostasis provided.

    More information on Vitalitec® titanium haemostatic clips in coronary artery bypass surgery. Request the brochure by clicking here.

     

    The right suture with the right properties for each anastomosis

    Suturing is not only a key phase in coronary artery bypass surgery for anastomosis, but is also used throughout the surgery, from opening the heart, to placing the cannulation, right through to the closure stage. The surgeon’s technique is not the only parameter that can affect the efficacy of the sutures. Making the right choice of material at each stage of the surgery is essential to ensure the right tensile strength, watertightness and knot strength, while reducing trauma to the tissues. Peters Surgical has been manufacturing and marketing a wide range of absorbable and non-absorbable sutures, for tissue approximation and/or ligation for over 50 years, to meet the needs of cardiac surgeons. Non-resorbable monofilament sutures such as Corolene® (polypropylene) and Premio® (PVDF) are preferable for anastomosis.

    Corolene®, a non-absorbable polypropylene monofilament suture usually used for coronary bypass anastomoses, provides either the same or greater (depending on the size of the threads) knot tensile strength as another brand of thread of the same type in an in-vivo animal model study2. Premio® sutures are designed for use in soft tissue approximation and/or ligation in cardiovascular, vascular, general and neurosurgery. Its inert PVDF (polyvinylidene fluoride) monofilament composition gives it high elasticity and knot strength for confidence and safety during coronary surgery. A study comparing PVDF yarns with polypropylene yarns showed that the PVDF yarn retained a high tensile knot strength over 7 years (≈ 95% residual tensile knot strength over 7 years) with better results than polypropylene yarns (≈60% residual tensile knot strength over 7 years).3

    During Extracorporeal Circulation (ECP) procedures, the suture material must also have good gliding properties for easier cannula placement and good knot security to ensure that the cannula is fixated effectively. The Polytresse® non-absorbable polyester braid is preferred for this stage, from exposure of the pericardium to closure of the sternum and skin. Peters Surgical’s comprehensive range of sutures can be used by surgeons at every stage of cardiac procedures to ensure the right suture properties at the right time.

    For more information on Peters Surgicals’ full range of sutures, request the brochure by clicking here.

     

    Spotlight on an innovative technology: proximal anastomosis without clamping

    The Enclose® II system is an innovative device for use in proximal anastomosis, replacing partial clamping of the aorta during beating-heart coronary bypass surgery. It is an alternative to traditional partial aorta clamping using a surgical clamp and can be significantly beneficial to the safety of the procedure3. There is a risk of fracturing the atheromatous plaques when a surgical clamp is placed on an atheromatous aorta, followed by emboli or microfragment dissemination when the clamp is removed, which could increase the risk of stroke, kidney damage or mesenteric ischaemia4,5.  Surgical clamps may also cause trauma to the aortic wall or cause dissection. A temporary vascular occlusion system, such as Enclose II, exerts significantly less pressure on the aortic wall than partial clamping, and can potentially reduce trauma and neurological damage to the vessels and provide the surgeon with a stable and unobstructed operating field3. This device also makes it possible to perform several anastomoses from a single insertion site. Enclose® II has been the subject of several clinical studies to assess its efficacy and safety since the 2000s.  These studies have shown that Enclose II provides a very good graft patency rate (96.4% on average one year after surgery on 222 proximal anastomoses, 178 patients) 6.  The studies showed that Enclose® II had a good safety of use, with no evidence of aortic injury and no surgical complications related to plaque microfragments or emboli6.

    Find out more about the Enclose II system and its advantages by watching the webinar: Proximal anastomosis in CABG with Enclose® II device, presenting the experience of Dr Torregrossa, Cardiovascular and Thoracic Surgeon, Director of the Robotics and Revascularisation Programme at the Lankenau Heart Institute, Wynnewood, Pennsylvania -USA.

     

    Several devices and equipment have now been developed for optimum comfort for thoracic and cardiovascular surgeons during coronary bypass procedures and to guarantee patient safety, in particular through good haemostasis, which reduces trauma to the vessels.

    S.F.C.T.C.V: Société Française de Chirurgie Thoracique et Cardio-Vasculaire

    1. Logeais Yves. Naissance et évolution de la chirurgie cardiaque. Bull. Acad. Natle Méd., 2014, 198, no 9, 1717-1726, séance du 16 décembre 2014
    2. Etude SPS008-1207EN, Service R&D Peters Surgical. Les données reportées viennent d’une étude sur un modèle animal, les résultats observés ne peuvent pas être extrapolés chez l’Homme
    3. PVDF Monofilament sutures, Laroche G et al., Artificial organs -1995
    4. Boova RS, Trace C, Leshnower BG. Initial experience with the enclose proximal aortic anastomosis device during off-pump coronary artery bypass: an alternative to aortic side clamping. Heart Surg Forum. 2006;9(2):E607-11. PMID: 16543162.
    5. Dominici, C., Salsano, A., Nenna, A., Spadaccio, C., El-Dean, Z., Bashir, M., Mariscalco, G., Santini, F., Chello, M. (2019). Neurological outcomes after on-pump vs off-pump CABG in patients with cerebrovascular disease. Journal of Cardiac Surgery 34(10), 941-947.
    6. Abu-Omar, Y., Taghavi, F.J., Navaratnarajah, M., Ali, A., Shahir, A., Yu, L.M., Choong, C.K., Taggart, D.P. (2012). The impact of off- pump coronary artery bypass surgery on postoperative renal function. Perfusion 27(2), 127-131.
    7. Seto, Y., Yokoyama, H., Takase, S., Tanji, M., Takahashi, K. , Takahashi, S., Hirota, J., Kondo, S., Hagiwara, K., Watanabe, M. (2012). The results of the enclose II proximal anastomotic device in 17 8 off-pump coronary artery bypass surgeries. Innovations (Phila) 7(4), 242-246.

     

    Legal information.

    • Corolene®– Corolene® sutures are used generally for approximation and/or ligation of soft tissue, including in cardiac and vascular surgery, plastic surgery, ophthalmic surgery and neurosurgery. Corolene® sutures can be used for laparoscopic surgery of the abdominal aorta (specific codes for laparoscopic surgery). Medical Device Class III- CE 0459 –  Manufacturer: Peters Surgical
    • Cardioxyl® –  Cardioxyl® sutures are used generally for approximation and/or ligation of soft tissue, including in cardiac, vascular and ophthalmic surgery. Medical Device Class III- CE 0459 –  Manufacturer: Peters Surgical
    • Polytresse®  – Corolene® sutures are used generally for approximation and/or ligation of soft tissue, including in orthopaedic surgery, cardiac and vascular surgery and ophthalmic surgery. Medical Device Class III- CE 0459 –  Manufacturer: Peters Surgical
    • Titanium CLIP 9 Vitalitec® and SLS-CLIP Vitalitec® haemostatic clips –  Titanium haemostatic clips can be used in all surgical specialities that require complete occlusion of a vessel or tissue, with the exception of fallopian tube ligation. Medical Device Class III- CE 0459 –  Manufacturer: Peters Surgical
    • Applicateurs de clips hémostatiques Vitalitec®–  Vitalitec® haemostatic clip applicators are designed to load, hold and close Vitalitec® titanium haemostatic clips in an optimal way – Medical Device Class I- Manufacturer: Peters Surgical.
    • Vitalitec® endoscopic clip applicators – Vitalitec® endoscopic clip applicators are designed to load, hold and close Vitalitec® titanium haemostatic clips. Medical Device Class I- Manufacturer: Vitalitec International Medizintechnik GmbH.
    • Enclose® II Anastomosis device–  The Enclose® II device is intended for use by cardiac surgeons during coronary artery bypass graft (CABG) surgery, with or without a pump, to avoid using partial occlusion clamps in ascending aortas without atheroma.  Medical Device Class IIa- CE 2797 – Manufacturer: Vitalitec International Inc