title: A novel one-shot anastomotic stapler prototype for coronary bypass grafting on the beating heart: feasibility in the pig.
abstract: OBJECTIVE
  The nonpenetrating, arcuate-legged clip has proved its ability to provide a high-quality microvascular anastomosis. This study assessed the feasibility of constructing a coronary end-to-side anastomosis on the beating heart with a novel mechanical, sutureless anastomotic device that applies 12 circumferential clips simultaneously.
  
  
  METHODS
  In 14 consecutive pigs (70-90 kg), the left internal thoracic artery (diameter, 3 mm) was grafted to the left anterior descending coronary artery (diameter, 3 mm) by means of a one-shot anastomotic stapler prototype. Endothelial denudation, medial necrosis, and intimal hyperplasia were analyzed quantitatively and compared with those seen in conventionally sutured anastomoses (n = 4).
  
  
  RESULTS
  In 8 of 14 anastomoses, the one-shot anastomotic stapler successfully applied all 12 clips circumferentially across the everted arteriotomy edges. In the remaining, either 1 (n = 4) or 3 and 4 adjoining malaligned clips had to be replaced manually with a single-clip applicator. Coronary occlusion was limited to approximately 3 minutes. At follow-up, all anastomoses were patent angiographically. At 2 days, in 2 of 7 cases, a local coronary dissection was observed, and there was a considerable loss of endothelial cells and medial damage. At 28 days, however, minimal intimal hyperplasia was seen at the anastomotic lining, although more pronounced when compared with conventionally sutured anastomoses.
  
  
  CONCLUSIONS
  The one-shot anastomotic stapler prototype enabled short-occlusive (3 minutes), sutureless end-to-side grafting on the beating porcine heart. In spite of early endothelial and medial damage and 2 local dissections, all anastomoses remained patent with minimal intimal hyperplasia at 4 weeks.
authors.affiliation: Departments of Cardiology and Cardiothoracic Surgery, Heart Lung Institute, Utrecht University Hospital, Utrecht, The Netherlands.
authors.forename: R H
authors.initials: RH
authors.lastname: Heijmen
authors.forename: P
authors.initials: P
authors.lastname: Hinchliffe
authors.forename: C
authors.initials: C
authors.lastname: Borst
authors.forename: C W
authors.initials: CW
authors.lastname: Verlaan
authors.forename: C M
authors.initials: CM
authors.lastname: Mouës
authors.forename: Y J
authors.initials: YJ
authors.lastname: van der Helm
authors.forename: S
authors.initials: S
authors.lastname: Manzo
authors.forename: E W
authors.initials: EW
authors.lastname: Jansen
authors.forename: P F
authors.initials: PF
authors.lastname: Gründeman
mesh_terms: D000714:Anastomosis, Surgical / Q000295:instrumentation; D000818:Animals; D001026:Coronary Artery Bypass / Q000295:instrumentation*; D003331:Coronary Vessels / Q000473:pathology / Q000601:surgery*; D004867:Equipment Design; D005240:Feasibility Studies; D006965:Hyperplasia / Q000473:pathology; D017792:Surgical Stapling; D013552:Swine; D017539:Tunica Intima / Q000473:pathology