Cardiovascular Engineering and Technology (Ó 2016)

DOI: 10.1007/s13239-016-0274-x

Simulation of Anastomosis in Coronary Artery Bypass Surgery

HADI MOHAMMADI,1,2,3 BRET NESTOR,1 and GUY FRADET1,2
1
The Heart Valve Performance Laboratory, School of Engineering, Faculty of Applied Science, University of British Columbia,
Okanagan, Kelowna, BC V1V 1V7, Canada; 2Department of Surgery, Faculty of Medicine, University of British Columbia,
Vancouver, BC, Canada; and 3Biomedical Engineering Graduate Program, Faculty of Applied Science, University of British
Columbia, Vancouver, BC, Canada
(Received 25 February 2016; accepted 8 July 2016)

Associate Editor Ajit P. Yoganathan oversaw the review of this article.

Abstract—Developing cardiac surgical skills and experience
takes years of practice. Cardiac trainees need to develop
technical proficiency in order to enhance quality of care and
patient safety. Simulation-based models are common re-
sources for teaching procedural skills in both undergraduate
and postgraduate medical education. Suitable and accessible
educational platforms can play a progressively important
role in the training process for young surgeons in the area of
cardiac surgery. Coronary artery bypass graft (CABG)
surgery consists of a wide range of pathologic anatomies
and surgical techniques. In this paper we introduce a novel,
synthetic, biomimetic platform that allows for the realistic
practice of the CABG surgery. The prototype uses a
polyvinyl alcohol hydrogel which has been designed to
mimic the geometric properties of vasculature. The proposed
models look and feel like human tissue and possess somewhat
consistent mechanical properties. In this study, we apply the
platform to simulate a case of autogenous saphenous vein
bypass grafting of a patient. An autogenous saphenous vein
graft is placed from the aorta to the left anterior descending
coronary artery. The standard procedures of the coronary
artery bypass surgery were successfully simulated. Using the
proposed technology, other complicated surgeries such as
end to end, side to end, and sequential anastomoses can be
simulated such that these models lend themselves very well to
various types of anastomoses.
Keywords—Hydrogel biomaterials, Anastomosis, Surgical
tools, Cardiac training, Bypass surgery, Reconstructive
surgery.
INTRODUCTION
Acute myocardial infarction (AMI) results from a
partial or complete obstruction of a coronary artery
branch. To mediate the incident of this risk, the coro-
nary artery bypass graft (CABG) surgery is conducted.
The procedure harvests a similar vessel in topology and
mechanical properties from elsewhere in the body such
as the saphenous vein located in the leg.8,10 Meanwhile,
the surgeon exposes and either stops the heart and puts
the patient on a cardiopulmonary support machine, or
continues the surgery while the heart is still beating on
its own accord.4 The harvested vein is grafted onto the
coronary artery distally and to the ascending aorta
proximally so that a bridge is made between the
ascending aorta and a location after the constricted
section. The grafted vein provides a bypass that diverts
the flow of blood around the plaque in the coronary
artery so that it may reach the heart tissue.
The issue is that there is no synthetic platform which
can realistically simulate the coronary artery bypass
surgery. The current platforms are mechanically inac-
curate artificial models or animal models. Animal
models offer similar mechanical properties as human
anatomy, however, they are not accessible for frequent
practice. Also, there are numerous limitations in using
animal models which have been mostly addressed in
our proposed synthetic platform. In this study, we offer
synthetic models of coronary artery vascular grafts
with fairly similar geometrical properties. These mod-
els also possess consistent mechanical properties to
that of the native tissue. The proposed platform is an
excellent platform which might be used for the simu-
lation of anastomosis as applied in coronary artery
bypass surgery.

Address correspondence to Hadi Mohammadi, The Heart Valve METHOD

Performance Laboratory, School of Engineering, Faculty of Applied
Science, University of British Columbia, Okanagan, Kelowna, As to the topology of the coronary artery, it was
BC V1V 1V7, Canada. Electronic mail: hadi.mohammadi@ubc.ca found that the wall thicknesses of the coronary arteries

Ó 2016 Biomedical Engineering Society

 MOHAMMADI et al.

varied from 0.42 to 1.35 mm.1 The saphenous vein wall Hydrogel Preparation
thicknesses tended to be roughly 0.79 mm ± 20 lm.11
We have designed a manufacturing procedure to
The lower-bound coronary artery outer diameter was
produce synthetic models of coronary arteries in
reported to be 1.2 mm,5 whereas the upper-bound
varying of sizes which have compatible mechanical
harvested saphenous vein diameter was reported to be
properties and geometry to that of human tissue. Our
7 mm with an average minimum diameter of 3.6 mm
proposed synthetic models simulate a consistent tissue
and an average maximum diameter of 4.84 mm within
resistance and strength while lacerating and suturing.
one vessel length.5

FIGURE 1. (a) CAD design (b) actual prototype of the mold for the fabrication of synthetic grafts. 12 grafts with varying of sizes
are fabricated in the same batch and (c) Tensioning mechanism, the conic fixture holds the cord always at the center and the spring
behind it ensures of a minimal tension on the cord so it is always strengthened.

FIGURE 2. The prototypes of synthetic small grafts made of 10% hydrogel. The models include 10 sizes of arteries, ranging from
1.5 to 7 mm to provide accommodations for all of the possible sizes used in CABG.
 Simulation of Anastomosis in Coronary Artery Bypass Surgery

This consistency has been achieved by using a (RA) grafting). The average internal diameter for the
mechanically tuned hydrogel. Polyvinyl alcohol (PVA), human saphenous vein is reported to be 1.75 mm
99+% (Sigma-Aldrich) hydrolyzed with a molecular without distention and 2.18 mm with distension.11 The
weight of 146,000–186,000, was applied for the solu- artery and vein cores selected for the design range from
tion preparation. The detail of material preparation is 1 to 2.5 mm. The length of the hydrogel conduit was
discussed in our previous studies.7,9 The preselected chosen carefully to provide more material for the
hydrogel material requires a thermal cycling process to consumers to use, and to ensure that the device fit
mechanically and physically crosslink the long mole- within the coolant bath. This criterion has been met
cules. Therefore, the design is restricted to molds that through carefully selected design and fabrication pro-
fits with the anti-freeze cooling bath (15L Heating Bath cesses. The geometry of the vessels is simplified to that
Circulator Model SD15H170-A11B). This requires of a 10 cm long tube of constant diameter and wall
that the mold be resistant to the ethylene glycol solu- thickness.
tion and a temperature range from 20°C to room The process needs to be suitable for lab production
temperature.6 and produce sanitary vessels ready for use in a medical
environment. The device must be easy to use in a lab-
oratory environment as the main consumers will be
Mold Design
surgeons or medical practitioners. With minimal
The design features 10 sizes of arteries, ranging from instruction for securing the device, the final hydrogel
1.5 to 7 mm to accommodate for all of the possible vessels should be easy to create, and extract. If possible,
sizes used in CABG (to include saphenous vein (SVG), no extraneous tools should be required in the operation
internal mammary artery (IMA) and radial artery of the device. The mold must be easy to maintain and
clean. Each part must be easy to access for the techni-
cians and no trouble to dismantle and store.
TABLE 1. Dimensions of the proposed synthetic models to
be used for the simulation of small grafts anastomosis. In order to achieve the specified dimensions, a flat
plate design was employed. This design involves two
OD (outer diameter) mm Thickness flat symmetrical plates with the dimensions of each
1.5 350 lm
artery size etched into a semicircular channel. When
2.1 500 lm these components mate they create a cylindrical tube.
2.9 670 lm This can be observed in Figs. 1a and 1b.
3.4 820 lm To reduce the cost of the mold, the cores were de-
4.2 940 lm signed to accommodate polymer cords. It has provided
4.8 1.2 mm
5.5 1.4 mm
us with straight cores, simple fastening mechanisms,
6.1 1.8 mm and the ability to use off-the-shelf components. The
7 2.0 mm luminal diameters of the vessels are permitted to be
modified by switching cord sizes for minimal cost.

(a) (b)

(c) (d) CABG (e)

site

Penetration of the blue liquid into

the coronary artery

FIGURE 3. Anastomosis of a graft to the coronary artery in a Pig Heart Model. (a) Preparation on the coronary artery and the
estimation of the location of anastomosis, (b) the suturing the graft to the location of anastomosis, (c), (d), (e) are the cannulation
test. A blue aquatic liquid is perfused through the graft by creating an adequate pressure and the location of anastomosis is
checked for leak.
 MOHAMMADI et al.

Another issue addressed by this design is the ability
for the cores to be concentric with the mold cavity. Our
unique solution is to apply the tension in the cores
through a conical centering system. It ensures that the
cores remain centered regardless of orientation or
disturbance imparted on the mold during the manu-
facturing process. The conical mechanism features a 45
degree taper on each end of the cylinder. This current
design is displayed in Fig. 1c.
This design allows for a more intuitive system with
less intricate components. The commercially available
compression springs ensure that the cord is under
tension throughout expansion and contraction of the
various temperature cycles. We found that during the
manufacturing process it was difficult to tie or untie the
half hitch knot required to secure the cords. To combat
this, we used readily available cord locks. These de-
vices were sufficient in holding tension in the polymer
cores.
Mold Fabrication
The 3D rendering of the mold was created on So-
lidWorks R2015 software. Renderings were printed

FIGURE 4. Demonstration side to side anastomosis using the fabricated graft in this study. (a) 3 synthetic grafts used in this
study. (b) demonstration of making a longitudinal incision, (c) demonstration of a side-to-side anastomosis theoretically, (d), (e),
and (f) are the standard steps for the side-to-side anastomosis12, (g) corresponding to step (d) on the synthetic graft, (h) corre-
sponding to step (e) on the synthetic graft, and (i) completion of the anastomosis on the synthetic graft.
 Simulation of Anastomosis in Coronary Artery Bypass Surgery
using a Connex 500 (Proto 3000, Mississauga, Canada)
3D printer with a tolerance of 60 lm. The mold may
use other polymer manufacturing processes to reduce
cost and increase throughput of production for future
manufacturing.
RESULTS AND DISCUSSION (APPLICATION)
PVA Hydrogel Models
The developed material which possesses consistent
mechanical properties to those of the coronary artery
tissue is implemented for the final models. The de-
signed and fabricated molds are now filled with the
proposed hydrogels (10% PVA-c) and the final models
are manufactured. These models are similar in geometry
and possess compatible mechanical properties to that of
native tissues and are suited to model vasculature for
the simulation of aortic heart valve surgery (Fig. 2). In
comparison with the native arteries, the values of cir-
cumferential strength of the synthetic coronary artery
models reported here is 0.50 ± 0.12 MPa compared to
that of the native tissue which is 0.39 ± 0.07 MPa.2,3
The results of both models (the synthetic and the native
tissue) are consistently close with less than 5% dis-
crepancy.
Our design can produce vessels with a mean outer
diameter of 1.30 mm and a mean luminal diameter of
600 lm. The measurement of the vessel thickness is
350 lm. These vessels have an average vessel length of
60 mm. Thus, vessels have successfully been manu-
factured in the micron range. We are able to consis-
tently create vessels between 1.5 to 7 mm outer
diameter with an average length of 60 mm as shown in
Fig. 2 (also see Table 1).
FIGURE 5. (a) Other techniques used for the side-to-end anastomosis, (b) end-to-end anastomosis, both on our synthetic pro-
posed models.
End to Side Anastomosis
We used a variety of Prolene (polypropylene) suture
sizing from 2.0 to 6.0. The obtuse marginal is incised
and the incision is extended with scissors as shown in
Fig. 3a. A suture is passed through the artery, then
through the vein, and then through the artery and
tagged. The other end is brought through the vein, and
the vein is lowered into place. The suture line is then
brought up to the right side. The other suture is brought
through the heel of the vein, through the artery, up the
left side and around the toe, thereby completing the
suture line as shown in Fig. 3b. In the end, a cannula-
tion is performed to ensure of an effective connection of
the graft to the artery Figs. 3c, 3d, and 3e.
Side to Side Anastomosis
We used a variety of Prolene (polypropylene) suture
sizing from 2.0 to 6.0. The grafts are prepared as
shown in Fig. 4a. Both grafts (grafts A and B) are
notched longitudinally (and not transversely) (Fig. 4b).
The incision must be precise otherwise an inappropri-
ate incision may lead to the least amount of constric-
tion of the graft at the location of anastomosis. The
suturing process follows that of shown in Figs. 4c, 4d,
4e, and 4f. A suture is taken inside-outside the artery
(graft A) and labeled. The suture line is brought up
inside-outside the vein (graft B) and outside-inside the
artery (graft A) (Figs. 4g, 4h). The suture is brought up
outside-inside the vein (graft B) and inside-outside the
artery (graft A) and around the end of arteriotomy to
complete the anastomosis (Fig. 4i).
There are other techniques which can be used
for the side-to-side or the end-to-end anastomosis
(Figs. 5a, 5b) that we do not intend to explain in detail.
 MOHAMMADI et al.

(a) (b)

Aortic
Valve
Aortic Leaflets
Sinuses

FIGURE 6. (a) Side to side anastomosis of a small graft to the ascending aorta, (b) top view of the ascending aorta and the small
graft both of which are our synthetic proposed models.

In the last step, side to side anastomosis of a small availability of practice tools for surgeons will con-
graft to the ascending aorta was performed as shown in tribute to improving their proficiency and confidence
Fig. 6. The ascending aorta used in this study is made in cardiac operations.
of the same hydrogel biomaterials but with mechanical
properties similar to those of the leaflet tissue and the
vessel wall. This model includes the sinuses and the
aortic valve incorporated all in one piece. Using the
proposed technology, side to side anastomosis of a ACKNOWLEDGMENT
small graft to the ascending aorta was achieved in a
The authors acknowledge the University of British
realistic simulated and synthetic platform.
Columbia and NSERC (Discovery Grant) for financial
support.
CONCLUSION

In this study, for the first time to the best of the CONFLICT OF INTEREST
authors’ knowledge, a new method for producing No conflict of interest.
artificial hydrogel micro-vessels is presented to satisfy a
lack of accessibility to coronary artery bypass practice
materials. Until now, small hydrogel vessels have not COMPETING INTERESTS
been produced due to their intricate geometries. The
vessels feature a material with mechanical properties None declared.
and geometric properties which are not statistically
dissimilar from human vessels. The samples have been
successfully applied to simulate a coronary artery by- SOURCE OF FUNDING
pass procedure. The penetration ability of the sutures Start-up Grant, University of British Columbia.
in variety of sizes (from 2.0 to 6.0) was tested using
prolene (polypropylene) suture which was satisfactory.
The proposed material seems to be compatible with
REFERENCES
ployglasctin (vicryl) sutures as well.
For future work, the suture penetrating ability (by 1
comparing different sutures polyglactin (vicryl) vs Claes, E., J. M. Atienza, G. V. Guinea, F. J. Rojo, J. M.
Bernal, J. M. Revuelta, and M. Elices (n.d). Mechanical
prolene 5-0/6-0/7-0) using a semi quantitative scoring properties of human coronary arteries.
approach can be tested. Also, suture retention by 2
Elmistekawy, E. M., N. Gawad, M. Bourke, et al. Is
showing some pull test data compared to the actual bilateral internal thoracic artery use safe in the elderly? J.
tissues can be studied. A short case study showing the Card. Surg. 27:1–5, 2012.
3
suitability of the hydrogel vessels in a simulated model Kieser, T. M., A. M. Lewin, M. M. Graham, et al. Out-
comes associated with bilateral internal thoracic artery
to train a few operators and its outcomes (semi grafting: the importance of age. Ann. Thorac. Surg.
quantitative scoring means) will be performed. The 92:1269–1275, 2011; (discussion 1275-6).
 Simulation of Anastomosis in Coronary Artery Bypass Surgery
4 9
Konstantinov, I. E., and I. Vasilii. Kolesov: a surgeon to Wan W. K., L. E. Millon, H. Mohammadi. Anisotropic
remember. Tex. Heart Inst. J. 31:349–358, 2004. hydrogels for use in tissue replacement and reconstruction,
5
Leask, R. L., J. Butany, K. W. Johnston, C. R. Ethier, and bioagent entrapment and delivery, therapy pads and other
M. Ojha. Human saphenous vein coronary artery bypass medical goods. U.S. and International PCT Provisional
graft morphology, geometry and hemodynamics. Ann. Patents (2005-6), (US No.2005/60/666,316-PCT No.2006/
Biomed. Eng. 33(3):301–309, 2005. 000477).
6 10
Millon, L. E., H. Mohammadi, and W. K. Wan. Aniso- Zareh, M., G. Fradet, B. Naser, and H. Mohammadi. Are
tropic polyvinyl alcohol hydrogel for cardiovascular two-dimensional images sufficient to assess the
applications. J. Biomed. Mater. Res. Part B Appl. Bio- atherosclerotic plaque vulnerability?—a viscoelastic and
mater. 79(2):305–311, 2006. anisotropic finite element model. J. Cardiovasc. Syst.
7
Mohammadi, H. Nanocomposite biomaterial mimicking 3(3):1–11, 2015.
11
aortic heart valve leaflet mechanics. J. Eng. Med. Zhao, J., J. Jesper, J. Yang, B. Steen Rasmussen, D. Liao,
225(7):718–722, 2011. and H. Gregersen. Manual pressure distension of the
8
Mohammadi, H., and K. Mequanint. Effect of stress human saphenous vein changes its biomechanical proper-
intensity factor in evaluation of instability of atheroscle- ties-implication for coronary artery bypass grafting. J.
rotic plaque. J. Mech. Med. Biology 14(5):1450072, 2014. Biomech. 40:2268–2276, 2007.