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Address for reprints: Vasily I. Kaleda, MD, Department of Cardiac Surgery, Central Clinical Hospital, Moscow, Russia, 15, Marshala Timoshenko St, Moscow, 121359, Russia.
Department of Cardiac Surgery, Central Clinical Hospital, Moscow, RussiaDepartment of Cardiovascular Surgery, School of Continuing Medical Education, Pirogov Russian National Research Medical University, Moscow, Russia
Its threat is a turbulence flow that may trigger clot formation within the graft. The main cause of the seagull deformity is too-long incision of a target coronary artery, which leads to the transverse tension of the graft with its flattening and kinking at the anastomosis. In addition, the position of the target coronary artery deep in the myocardium and stiffness of its wall may amplify the impact of the excessive incision length. Another cause of the deformity is when some redundant adventitial tissue is dragged to the anastomosis while sewing. Strategies to avoid this complication have been described by numerous authors,
but little is known about how to address a seagull deformation if it is already occurred. The traditional approach is to redo the anastomosis using a parallel side-to-side or end-to-side technique, which means switching to a completely different graft strategy. Here, we describe an easier way to solve this complication.
Figure 1Schematic representation of the patch repair technique for the seagull deformity of a sequential diamond-shaped anastomosis. A, Seagull deformity. B, Longitudinal incision of the graft just over the anastomosis. C, Closing the incision with a diamond-shaped patch. D, Final view of the repair.
As we mentioned earlier, the mechanism of the seagull deformity includes transverse tension of the graft. This means a lack of graft tissue to close a large incision of the coronary artery. Hence, one of the ways to address with this complication is to add some extra tissue to the graft. For this purpose, a longitudinal incision is made on the graft just over the anastomosis (Figure 1, B). Then, this incision is closed with a diamond-shaped patch from the same tissue as the graft (Figure 1, C and D). Video 1 shows this technique by means of a high-fidelity simulation model. We used this technique clinically in 2 patients with a good immediate result.
Discussion
Here, we describe a patch repair technique for the seagull deformity of a sequential diamond-shaped coronary anastomosis, which seems to be the easiest way to solve this complication. However, this technique has some limitations. First, it adds an extra suture line at the site of the anastomosis, increasing the risk of technical errors, which may lead to endothelium damage and subsequent clot formation. Second, some grafts may be too fragile for patch repair (however, such grafts are not likely to be used for sequential anastomoses). And, finally, this technique has not been proven with long-term follow-up. Nevertheless, alternatives to the described technique are even more risky, as they mean switching to a new graft configuration in the middle of the procedure.
Conclusions
Seagull deformity of a sequential diamond-shaped coronary anastomosis may be easily solved with a patch repair technique.
We thank Prof Teresa M. Kieser for some essential tips while preparing this manuscript and Julia Tochilina for her illustrations.
Patch repair technique for the seagull deformity of a sequential diamond-shaped anastomosis is shown by means of a high-fidelity simulation model (a bovine heart and a cryopreserved saphenous vein). Video available at: https://www.jtcvs.org/article/S2666-2507(23)00006-8/fulltext.
Patch repair technique for the seagull deformity of a sequential diamond-shaped anastomosis is shown by means of a high-fidelity simulation model (a bovine heart and a cryopreserved saphenous vein). Video available at: https://www.jtcvs.org/article/S2666-2507(23)00006-8/fulltext.
References
Lemma M.G.
Technique for Y and T grafts.
in: Gaudino M. Technical Aspects of Modern Coronary Artery Bypass Surgery. 1st ed. Academic Press,
2020: 99-113
Read at the Eighth International Coronary Congress, Tokyo, Japan, December 1-3, 2022.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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