Sutureless coronary anastomoses: revival of old concepts

Surgical environment is becoming increasingly challenging for the cardiac surgeon since off-pump coronary arteries bypass grafts and minimally invasive approach came up. The suture technique for coronary anastomosis construction is becoming inadequate to meet new surgeons' demand. Therefore, there is an increasing need for alternative ways to perform coronary bypasses. This article reviews the most recent devices developed for cardiac surgery (Q-Cab and distal connector from St. Jude Medical, CoreLink from Ethicon, GraftConnector from Jomed Int.), and demonstrates that the new anastomotic technologies are based on concepts expressed by Payr and other authors in the 19th century. We propose to consider three aspects to evaluate a sutureless anastomotic device: the device-vessel wall connection, the graft preparation and the anastomosis' biomechanical properties. Pins, wall eversion on an anvil and squeezing are the three systems used to anchor the connector to the graft and to the native artery. The graft preparation and anastomotic biomechanics are analysed with respect to the possibility of affecting graft patency rate. Finally, we trace the profile of the ideal anastomotic device: minimal graft manipulation, no limitation in anastomotic timing, no material in the vessel lumen and optimal anastomotic angle and compliance. The evidence of long-term graft patency is fundamental for any anastomotic device to become widely acceptable.