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Updated: Aug 14, 2026
Vessel-sparing Excision and Primary Anastomosis
Published on: January 7, 2019
Vettath's anastamotic obturator--our experience of 269 proximal anastomoses
Murali P Vettath1, A V Kannan, C S Sheen Peeceeyen
1Department of Cardiac Surgery, Malabar Institute of Medical Sciences, Mini Bypass Road, Govindapuram PO, Kozhikode, Kerala, India. mvettathcts@hotmail.com
Insights
This study introduces the Vettath's Anastamotic Obturator (VAO), an affordable device for coronary artery bypass grafting (CABG). The VAO facilitates off-pump CABG (OPCAB) by enabling proximal anastomoses without aortic side clamping, reducing neurological risks.
Area of Science:
- Cardiovascular Surgery
- Medical Device Innovation
- Minimally Invasive Cardiac Procedures
Background:
- Coronary artery bypass grafting (CABG) has evolved, with a renewed focus on off-pump techniques to mitigate neurological complications.
- Neurological issues persist even in off-pump CABG (OPCAB), with aortic side clamping identified as a potential major factor.
- Existing proximal anastomotic devices are often prohibitively expensive, particularly in developing countries.
Purpose of the Study:
- To develop and evaluate an indigenous, cost-effective device for proximal anastomoses during CABG.
- To introduce the Vettath's Anastamotic Obturator (VAO) as an alternative to expensive commercial devices.
- To assess the safety and efficacy of the VAO in facilitating 'no-touch' proximal anastomoses in OPCAB procedures.
Main Methods:
- The Vettath's Anastamotic Obturator (VAO), a stainless steel device, was designed for creating proximal saphenous vein graft (SVG) anastomoses onto the aorta.
- Following animal model trials, the VAO was used in 177 OPCAB patients, performing 269 proximal anastomoses over one year.
- The device was employed in various configurations (single, double, triple) and even on aortas with palpable plaques, with initial procedures favoring proximal-first anastomoses.
Main Results:
- No operative mortality was observed in the 177 patients undergoing procedures with the VAO.
- No patients required intra-aortic balloon pump (IABP) support post-operatively.
- Long-term follow-up revealed patent grafts and symptom-free lives for most patients, with only one instance of angina reported three months post-surgery.
Conclusions:
- Avoiding aortic side clamping with devices like the VAO is logical for reducing neurological complications in CABG.
- The Vettath's Anastamotic Obturator (VAO) offers an indigenous, reusable, and affordable solution for proximal anastomoses.
- Despite a potential learning curve, the VAO demonstrates gratifying results with few complications, making it suitable for resource-limited settings.
Background:
Coronary artery bypass grafting (CABG) has come full circle-it started as an off-pump affair, then became an on pump one and now we are trying to keep off the pump again. One of the main reasons for this has been the neurological sequelae subsequent to CABG. But neurological problems kept causing concern even in off-pump CABGs (OPCAB). Side clamping the aorta was thought to be the major factor and thus came the concept of 'no touch proximal anastomoses' onto the aorta (1). Though a variety of proximal anastamotic devices are available in the market, high cost is a matter of real concern in third world countries like India. Hence, this endeavor of ours to fabricate an anastamotic device of our own-'the Vettath's anastamotic obturator' (VAO) for proximal anastomoses of saphenous vein grafts (SVG) onto the aorta. VAO is a stainless steel rod with three grooves and a guard at the end, which sinks into the aorta, through a punch hole, cordoned off by two wide purse string sutures.
Methods:
After trials on perfused animal heart models, we started using this device on humans. We have performed 269 proximal anastomoses using the VAO in 177 of our OPCAB patients in the past 1 year (till July 2003). Ninety-five of them had single top ends, 72 had 2 top ends and 10 had 3 top ends onto the aorta. We have used this on disease free islands on four patients with palpable aortic plaques. Initially all anastomoses were of the proximal first type (to ensure that the flow was adequate). Now-a-days, with confidence, distal first anastomoses are being performed.
Results:
We had no operative mortality in this group. None of our patients needed IABP support. One patient reported back with angina, after 3 months-he was studied and his grafts were found to be patent. All patients, except three, are being followed up till date and they are leading active symptom free and event free lives.
Discussion:
It is logical to think that avoidance of side clamp on the aorta reduces the risk of neurologic complications. Vettath's anastamotic obturator is an indigenous, cheap and reusable alternative to the other costlier devices, which serve the same purpose. Though there is a small learning curve, results are gratifying and complications are few.
