Coronary anastomoses are vascular connections that can be either end-to-side or side-to-side,
both capable of excellent results. The side-to-side configuration, commonly used
for jump grafts where one graft feeds two coronaries, also can be converted to a
pseudo end-to-side anastomosis by simply ligating or clipping the open, free end
of the graft. The advantages of this configuration are: (1) the open free end of
the graft allows inspection of the anastomosis before it is clipped, and (2) the
risk of graft kinking is minimized because the graft runs in the same plane as the
target coronary artery and accommodates any desired crossing angle. .
The surgeon starts with making an incision or arteriotomy to create the anastomotic
orifice, and then sutures the vessel wall rims together with 8-16 tiny stitches,
typically 0.5 mm from the rim. This is a delicate task since precision is required
and since experience has taught that minimal tissue handling and a minimum amount
of foreign material on the inside produces the best long term results. Most surgeons
use one continuous or running suture as it saves time, having to tie only one knot
to complete the anastomosis. The disadvantage, however, is that too much suture tension
results in a stenotic or narrowed anastomosis, a phenomenon that is referred to as
the ‘purse string’ effect. To avoid this happening, some surgeons tie each stitch
individually, the so called interrupted suture technique. During anastomotic construction,
which can take anywhere between 10-20 minutes, the bloodstream is temporarily occluded
or stopped in order to maintain a bloodless field. The human heart generally tolerates
this lack of blood supply or ischemia well for this limited period of time, but some
surgeons prefer using a shunt to continue supplying the heart with blood.
