*2.2.3 Anastomosis*

*Cardiac Diseases - Novel Aspects of Cardiac Risk, Cardiorenal Pathology and Cardiac Interventions*

postoperative neurological complications [4]. Calcification of ascending aorta is an independent risk factor for cerebrovascular events after OPCABG, especially for postoperative stroke [3]. Therefore, careful exploration and accurate management of the ascending aorta are important. Traditional proximal anastomosis in OPCABG requires partial blocking of ascending aorta with side wall clamp; however, for patients with ascending aortic disease (e.g., serious ascending aorta atherosclerosis), connective tissue disease-related arteritis and syphilitic arteritis, the mechanical damage of aortic intima may be caused by the lateral cutting force produced by side wall clamp, which may lead to the rupture, dissection of aorta, rupture and detachment of atherosclerotic plaque and other serious perioperative complications. In recent years, a large number of auxiliary devices for proximal anastomosis of grafts have emerged, which can complete great saphenous vein-aortic anastomosis safely, simply, reliably and quickly without clamping ascending aorta, including commercial proximal anastomosis auxiliary device (Enclose, Heartstring, etc.) [7–9], original auxiliary device (urethra catheter-water sac) or no-clamp surgical techniques for proximal anastomosis [10–12]. This chapter will mainly introduce the

anastomotic method of the auxiliary device of proximal anastomose.

**2.1 Composition and principle of Enclose II anastomotic device**

Proximal anastomosis auxiliary device was introduced to resolve the disadvantage of side wall clamping [13]. These devices were designed to avoid clamping the lateral wall of the aorta and to reduce complications of the ascending aorta and the nervous system. For patients undergoing CABG, OPCABG is recommended to reduce the risk of cerebral complications caused by side wall clamping. Selective use of Enclose proximal anastomotic device in patients with severe ascending aorta

The device is composed of upper and lower rhombic mechanical jaws. The upper knob can adjust the vertical movement of the upper jaw, and it can make the upper and the lower jaws match at the anastomosis position of the ascending aorta to form a low-pressure cavity. The lower knob controls the opening and closing of the rhombic membrane at the end of the lower jaw, which makes the proximal anastomose

The ascending aorta should be explored routinely to avoid the atherosclerotic area on the aortic wall. Puncture site should be selected in the softest part of anterior wall of ascending aorta. The diameter of anastomosis area is about 1 cm.

• First, a purse suture with 2–0 polypropylene suture and rubber sleeve is used at the insertion point, and then mean arterial pressure is maintained at 100 mmHg (1 mmHg = 0.133 kPa) by medical management. The aorta wall is

**2. Enclose technique**

atherosclerosis will be discussed in this section.

area form a bloodless field of vision.

**2.2 Method of application**

*2.2.1 Position selection*

*2.2.2 Placement*

**258**

Anastomosis of saphenous vein (A) to ascending aorta (B) is performed with 6–0 polypropylene suture. The local bleeding that affects the suture field can be removed by suction. At the same time, maintain systolic blood pressure of systemic circulation at 90–100 mmHg level to reduce bleeding and ensure full layer suture of aortic wall and then exhaust and knot (**Figure 2**).
