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.