A systematic review of the safety and efficacy of distal coronary artery anastomotic devices

Interest in minimally invasive and off-pump cardiac surgical techniques has promoted the development of automated distal anastomotic devices (DADs) to facilitate construction of coronary artery anastomosis. Several DADs have been proposed for potential use in coronary surgery. However, a number of technical failures and uncertainty around both short-term morbidity and long-term patency have limited the generalized uptake of these devices. A systematic literature search identified 28 studies, incorporating 970 patients who underwent coronary artery bypass grafting using a DAD. Eight different devices were identified including Heartflo, St Jude, U-clip, vessel closure system, C-port, magnetic vascular positioner and coronary anastomosis coupler. Thirty-day mortality, cardiac-specific mortality and myocardial infarction were equal between DADs and hand-sewn cases (1.3, 0.3 and 0.8%, respectively). The overall proportion of postoperative haemorrhage was higher in the anastomotic device group (2.3%) than in the group with hand-sewn anastomoses (1.5%) although not statistically significant. Overall graft patency was 97.2% at <1 month, 94.6% at 1-3 months and 92.3% at >3 months. Of the currently available systems, the U-clip device was found to provide the best overall postoperative outcomes, which included a patency of 96.1% at >3months. The current literature is limited by its predominantly observational study design and lack of directly comparative studies. Furthermore, inter-study variation in patient selection, anticoagulation strategies and follow-up periods prevents quantitative comparison. Future research necessitates multicentre randomized, controlled studies to provide a direct comparison of current and future anastomotic device systems with established hand-sewn techniques in both the short and long term.