**9. Vettath's technique of long mammary patch**

A single stabilizer is used if the arteriotomy is <4 cm. If it exceeds >4 cm, two stabilizers (one facing each other) are used for coronary stabilization. The arteriotomy extends distally to reach the normal lumen of LAD. Proximal extent of arteriotomy is kept just short of the most severe proximal lesion to avoid competitive flow from native LAD.

Distal coronary perfusion during anastomosis is maintained using conventional intracoronary shunts (Clearview, Medtronic Inc, Minneapolis, MN, USA). If the arteriotomy exceeds 3-4 cm, cut ends of aorto- coronary shunts (Quickflow, Medtronic Inc, Minneapolis, MN, USA) are used. These may be tailored to use in arteriotomies upto 6-7 cms. In this technique, hither to undescribed (Vettath's modification of aorto-coronary shunts), the distal perfusion tips of aorto- coronary shunts are cut and inserted into the coronary artery. The

In patients with diffusely diseased coronary arteries and in patients with diseased aortas, OPCAB has remained a life saver. We had developed the Vettaths anastomotic obturator (VAO) (Murali.P.Vettath,2003,2004) – which , is is an aortic anastomosis enabling device. This allows the surgeon to avoid the side clamp on the aorta, when a no touch technique is required in cases of diseased aorta. In patients with plaquey aortas, where a saphenous vein top end is to be connected, this could be used to make an anastomosis on a no plaquey zone in the aorta. The technique is to identify a soft spot and make two purse string sutures with 3.0 polypropylene around the intended zone of anastomosis. The purse strings are about a centimeter in diameter. A stab wound is made using a no.11 blade and an aortic punch is used to make a punch hole on the aorta. The VAO is then inserted into the hole and one of the 3.0 purse strings are used to snare the bleeding around the VAO if it persists. The aortic systolic pressure may be maintained at around 100 mm of Hg. The advantage is that this allows the surgeon to perform a hand sewn anastomosis on the vein graft. This is like the devices that are available in the market, like the Heartstring and the Enclose device. This is like an instrument and is made of steel and can be reused and could help in avoiding a stroke in elderly patients. We have performed more than 500 top ends using this device and is a good one to have in the armamentarium of a cardiac surgeon. This is also a good tool to use in redo CABG, when a proximal anastomosis could be made on the hood of the old vein

The VAO is also a useful tool in cases where a combined aortic valve replacement is done

The diffusely diseased coronary arteries have been a curse in the south East-Asian population, and more so in patients with Indian origin. This is seen in these patients in the younger age group and they are usually termed inoperable. The disease is so diffuse that grafting area in the coronary arteries are studded with plaques. We had developed our own technique of Vettath's technique of long mammary patch on LAD without endarterectomy on beating heart. We had performed this on more than 200 patients since the last 9 years. We have also published the same (Murali Vettath,2008 ) in couple of journals. In fact we have been reviewing these patients with coronary angiograms and the results have been quite

A single stabilizer is used if the arteriotomy is <4 cm. If it exceeds >4 cm, two stabilizers (one facing each other) are used for coronary stabilization. The arteriotomy extends distally to reach the normal lumen of LAD. Proximal extent of arteriotomy is kept just short of the

Distal coronary perfusion during anastomosis is maintained using conventional intracoronary shunts (Clearview, Medtronic Inc, Minneapolis, MN, USA). If the arteriotomy exceeds 3-4 cm, cut ends of aorto- coronary shunts (Quickflow, Medtronic Inc, Minneapolis, MN, USA) are used. These may be tailored to use in arteriotomies upto 6-7 cms. In this technique, hither to undescribed (Vettath's modification of aorto-coronary shunts), the distal perfusion tips of aorto- coronary shunts are cut and inserted into the coronary artery. The

with a CABG. Here it is useful when the side clamp needs to be avoided.

most severe proximal lesion to avoid competitive flow from native LAD.

**8. Diffusely diseased coronary arteries** 

**9. Vettath's technique of long mammary patch** 

**7. Vettath's anastamotic obturator** 

graft.

gratifying.

Fig. 8. Shows the Vettath's anastomotic obturator , the whole length of the device and the working end of the piece that goes into the aorta.

Re-Engineering in OPCAB Surgery 195

(a) The VAO is inserted into the vein hood of the blocked vein graft. In a re do CABG- On pump.

The use of intra-aortic balloon pump (IABP) either preoperatively or intraoperatively, to reduce operative risk and to facilitate posterior vessel OPCAB has been well documented. IABP has been useful in high-risk patients with left main coronary artery disease (> 75% stenosis), intractable resting angina, post infarction angina, left ventricular dysfunction

Preoperative IABP counterpulsation has been shown to have better outcomes compared with perioperative or postoperative insertion in critical patients, and off-pump surgical

In patients with high risk factors, higher mortality and morbidity rates have been demonstrated in spite of massive pharmacologic support combined with postoperative IABP support. IABP therapy results in a more favorable myocardial blood supply, increased stroke volume and cardiac output through augmentation of the diastolic pressure, and afterload reduction (Christenson, 1997, 1999).Intraoperative or postoperative IABP insertion has been reported to be associated with higher operative mortality rate and device-related

(d) The top end of the vein graft in a CABG plus AVR done without using side clamp

procedures have been advocated to reduce mortality in high-risk patients.

complication rate, as compared with preoperative use of IABP.

(b) The suturing being done on the top end of the vein graft.

(c) The anastomosed vein graft s in position.

(ejection fraction < 35%), or unstable angina.

**10. Role of IABP in OPCAB** 

Fig. 10. Shows:

Fig. 9. Shows the close up of the top end anastomosis in progress using the VAO

bulb is inserted into the end from where the blood flows (i.e., into distal coronary lumen if the flow is retrograde and vice-verse). If the shunt does not sit inside the coronary (or it bowstrings), it is tacked down with a tacking suture taken in the midpoint of arteriotomy. This tacking suture is taken out at the end of anastomosis, along with the shunt. We use 7-0 polypropylene for this tacking suture. Occasionally, when native coronary flow is negligible and/or coronary lumen is <1 mm, the LAD is snared proximally with circumferential suture and LIMA to LAD anastomose was done. LIMA is slit to match the coronary arteriotomy and LIMA to LAD anastomosis is performed using 7-0 polypropylene. The plaques are excluded from the lumen of the reconstructed LAD. Diagonals and perforators are included in the new lumen. Posterior 25% of reconstructed coronary artery is formed by native coronary artery and anterior 75% by LIMA . Approximately 10 minutes were taken to construct a 2cm patch and an additional 5 minute per each added centimeter of patch was taken for anastomosis.

The advantage of this technique is that the intima is left intact and no injury is made on it. The avoidance of endarterectomy is a definite reason for the patency in our study. We also do not add any anticoagulants or anything other medications, than those used for the normal CABG patients. Also that in spite of our long anastomosis, patients remain quite stable all along the anastomotic time.This technique of long patch has also been described by Takanashi [S.Takanashi,2003.]

Fig. 9. Shows the close up of the top end anastomosis in progress using the VAO

taken for anastomosis.

Takanashi [S.Takanashi,2003.]

bulb is inserted into the end from where the blood flows (i.e., into distal coronary lumen if the flow is retrograde and vice-verse). If the shunt does not sit inside the coronary (or it bowstrings), it is tacked down with a tacking suture taken in the midpoint of arteriotomy. This tacking suture is taken out at the end of anastomosis, along with the shunt. We use 7-0 polypropylene for this tacking suture. Occasionally, when native coronary flow is negligible and/or coronary lumen is <1 mm, the LAD is snared proximally with circumferential suture and LIMA to LAD anastomose was done. LIMA is slit to match the coronary arteriotomy and LIMA to LAD anastomosis is performed using 7-0 polypropylene. The plaques are excluded from the lumen of the reconstructed LAD. Diagonals and perforators are included in the new lumen. Posterior 25% of reconstructed coronary artery is formed by native coronary artery and anterior 75% by LIMA . Approximately 10 minutes were taken to construct a 2cm patch and an additional 5 minute per each added centimeter of patch was

The advantage of this technique is that the intima is left intact and no injury is made on it. The avoidance of endarterectomy is a definite reason for the patency in our study. We also do not add any anticoagulants or anything other medications, than those used for the normal CABG patients. Also that in spite of our long anastomosis, patients remain quite stable all along the anastomotic time.This technique of long patch has also been described by

Fig. 10. Shows:

