**2. Anatomical considerations**

The work area anastomosis is generally from the fourth intercostal space down (Fig. 1).

**3. Technique**

sternotomy.

space (Fig 3).

**Figure 3.**

The patients are prepared as for standard coronary bypass operation through medium

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http://dx.doi.org/10.5772/54880

A skin incision is made from the xiphoid up to the level between the third and fourth intercostal

The sternum is open and the left table is lifted to dissect the left mammary artery.

with 3mg/kg to maintain ACT more than 480 sec.

In the majority of the operations, we used a part of a normal Lima retractor. In the last patients **we created a new prototype retractor** that allows to potential perform a more friendly operation (Fig.4). The left mammary was dissected up to the third intercostal space, in general around 7 to 10 cm. isolated without the veins. It is important that the angle of the superior part where the mammary is attached to the sternum has to be be‐ low 20% to avoid any potential kinking. After the dissection was completed, (Fig.5), if the operation is only left internal mammary to LAD, we would heparinzed the patient

When the ACT is more than 480 sec. and the patient has a normal temperature we would cut the distal part of the left internal mammary 1cm approximately from the distal bifurcation. The mammary distance is measured first with the pericardium intact, if achieved the dia‐ phragmatic reflect of the pericardium it means that the length of the mammary is correct to perform a graft, also in the most distal segment of the LAD. After the pericardium is cleaned to identify the area of the pulmonary artery, the pericardium is open to the apex and towards the right around 5 to 6 cm., initially in that moment in most of the cases the area of the LAD is seen and the potential area of the anastomosis is defined, the distance with the heart, in normal position of the mammary, is measured to be sure there is not any potential kinking do to excess of the conduit. The retractor is changed (in the last 6 cases we used a new prototype system where you only change the angle without changing the piece) (Fig.4), the pericardium

#### **Figure 1.**

The relationship between breast and distance to the coronary arteries or the anastomosis potential place can be estimated preoperatively with different imaging techniques. With a simple chest radiograph, you can also estimate the distance from the tip of heart to the midline sternum, important factor in concordance with the anatomical variations of the thorax. In the Fig. 2 you can see an ideal case where you are able to access any territory of the heart with this incision.

**Figure 2.**
