Surgical Science, 2011, 2, 451-452
doi:10.4236/ss.2011.29098 Published Online November 2011 (http://www.SciRP.org/journal/ss)
Extended Use of Vettath’s Anastomotic Obturator (VAO)
Vettath Prabhakaran Murali*, Ismail E. Thazhkuni, Kannan A. Vellachamy
Malabar Institute of Medical Sciences, Kozhikode, India
Received June 8, 2011; revised September 21, 2011; accepte d O ct obe r 26, 2011
Abstract
Stroke rate in redo coronary artery bypass surgery has remained a stumbling block, where the aorta is used as
origin for the top end of the vein graft. Avoiding the side-clamp on these redo aortas by using the Vettath’s
Anastomotic Obturator (VAO) technique of anatomosing the vein graft could bring this down. We have also
been able to use this technique in combined aortic valve replacement and CABG. These two situations where
the VAO is used are elucidated here.
Keywords: Anastomosis, Coronary, Redo CABG, VAO
1. Introduction
Redo Coronary artery bypass grafting (CABG) has be-
come a common procedure in many surgical units.
Though it can be safely and effectively performed, stroke
rate in Redo CABG has been high in literature. Proximal
anastomotic devices have been found to reduce stroke
rates in CABG’s [1,2].
Vettath’s Anastomotic Obturator (VAO) is a proximal
anastomotic device developed by the author (MPV). In
our center, it has been used in more than 500 proximal
top end anastamosis of coronary vein grafts over the past
eight years. We have been able to avoid the use of aortic
side clamp on diseased and thickened redo aortas by em-
ploying this device. This avoids the release of calcium
from the aorta and there by avoiding stroke. Extending
its use to redo CABG as well as in aortic valve proced ure
and CABG is highlighted here.
2. Technique
VAO can be employed for both on pump and off pump
Redo-CABG. The approach is through median sterno-
tomy. It is universally observed that the proximal stump
of even totally occluded vein grafts are soft and offer an
ideal site for placing top ends of new vein grafts. These
sites are identified.
After completing distal anastomoses, a 3-0-polyprolene
purse-string suture is placed around the intended site of
top end anastomosis and it is snared. A No.11 knife is
used to make a stab incision in the center of the purse-
string suture. This hole is occluded with the left index
finger and punched out using a 4.5 mm aortic punch.
This site is again covered with left index finger to pre-
vent bleeding. Then the VAO (Figure 1) is inserted into
the punch hole and the snare is tightened just enough to
prevent bleeding. The proximal end of the vein graft is
then sutured to the new punch hole using 5-0-polypro-
pylene suture using the technique already described [4].
The same technique could be used to perform 2 or 3 top
ends (Figure 2).
Another similar circumstance where a side clamp on
aorta is better avoided is in combined aortic valve sur-
gery and CABG. Here, the presence of calcium on aortic
wall or the need to avoid crushing the aortic suture line
necessitates the use of VAO, if the surgeon intends to
perform the top end after release of the cross clamp for
want of space in short ascending aortic patients. The
proximal end of vein graft is connected to the aorta using
the aforementioned technique after removal of cross-
clamp.
3. Discussion
The need to put a side clamp on aorta for proximal anas-
tomoses of free grafts (either veins or arteries) has been a
stumbling block in atherosclerotic or calcified aortas.
Redo CABGs where ascending aorta is often thickened,
plaquey and stuck to the adjacent tissue is one such in-
stance. Similarly, the desire to avoid aortic side clamp
after closure of aortotomy (to avoid crushing of suture
line) in combined aortic valve and CABG procedures
also necessitates the use of alternative devices for
proximal anastomosis. VAO is an anastomotic device,

452 V. P. MURALI ET AL.
Figure 1. VAO—different views.
Figure 2. Operative photograph showing: (a) commencing
anastomosis using VAO; (b) anastomosis in progress; (c)
after completion of proximal anastomosis; (d) combined
aortic surgery and CABG using VAO.
which carries all the advantages of a proximal anastomo-
tic device, in the meantime enabling the surgeon to per-
form a good handsewn anstomosis under vision. The
advantage of this device is its reusablity and its afforda-
bility in the third world co untries.
The author has used this device to perform his proxi-
mal anastomosis in 20 redo CABG’s with no neurologi-
cal deficit. This proximal anastomotic device can also be
potentially used in short and thickened aortas and in
combined procedures (like Aortic valve replacement/
repair + CABG). The advantage of this device is its sim-
ple design, cost effectiveness and the ease of construct-
ing a good hand sewn anastomosis maintaining good
patency as mentioned in our previous reports [4].
4. References
[1] S. F. Aranki, P. S. Shekar, A. Ehsan, M. Byrne-Taft and
G. S. Couper, “Evaluation of the Enclose Proximal An-
astomosis Device in Coronary Artery Bypass Grafting,”
The Annals of Thoracic Surgery, Vol. 80, No. 3, 2005, pp.
1091-1095.
[2] R. S. Boova, C. Trace and B. G. Leshnower, “Initial Ex-
perience with Enclose Proximal Anastomotic Device
During off-Pump Coronary Artery Bypass: An Alterna-
tive to Aortic Side Clamping,” Heart Surgery Forum, Vol.
l9, No. 2, 2006, pp. E607-E611.
[3] M. P Vettath, “Vettath’s Anastamotic Obturator: A Sim-
ple Proximal Anastamotic Device,” The Heart Surgery
Forum, 2003, Vol. 6, No. 5, Article ID: 73305.
www.hsforum.com/vol6/issue5/2003-73305.html
[4] M. P Vettath, A. V. Kannan, C. S. Sheen Peeceeyen, A.
K. Baburajan, A. Vahab and M. P. Sujith, “Vettath’s An-
astamotic Obturator—Our Experience Of 269 Proximal
Anastamosis,” Heart, Lung and Circulation, Vol. 13, No.
3, 2004, pp. 288-290. doi:10.1016/j.hlc.2004.02.019