Use of a purse string suture in proximal coronary anastomosis to reduce size mismatch between conduit and aortotomy

BACKGROUND

Coronary artery bypass graft surgery commonly involves the use of the left internal mammary artery as a pedicled graft and the use of saphenous veins, radial arteries and/or right internal mammary arteries as free grafts from the aorta to the coronary arteries.¹ Size mismatch may occur between the conduit and the aortotomy (Fig 1). It is important to stop the bleeding without compromising the anastomosis or the blood flow from the aorta to the coronary arteries through the graft. We describe a simple method to resolve this issue.

Figure 1.

Size mismatch between aortotomy and conduit; proximal anastomosis is performed using a continuous suture

TECHNIQUE

The proximal anastomosis is performed in the usual fashion using a running suture (Fig 1). If there is generalised bleeding or ooze around the anastomosis, a separate stitch (6/0 polypropylene) is placed as a separate purse string concentrically around the aortotomy approximately 5mm from the anastomotic edge. The perfusionist or anaesthetist is requested to reduce the blood pressure and the purse string is then tied, leading to a reduction of the aortotomy in a uniform style, thereby causing the bleeding or ooze to stop (Fig 2).

Figure 2.

Purse string is placed around the aortotomy and proximal anastomosis, correcting the size mismatch

DISCUSSION

This simple and practical technique has been used by us successfully in several patients with size discrepancy between the conduit and the aortotomy. After tying the suture, there is a reduction in the tension at the proximal anastomosis and haemostasis is achieved. It also avoids the need to place extra sutures to secure the anastomosis, which can compromise both its immediate and long-term patency.²