**5.1 Harvesting of the conduit**

*Cardiac Surgery Procedures*

be assured.

**2. Surgical strategy**

distal to the stent.

either groups.

**4. Anaesthesia management**

**3. Preoperative preparation in OPCAB**

intraoperative and post-operative management till he returns to his room and to his further follow up, all are to be planned and executed with precision. Every patient needs to get a tailor made surgical approach. As, no two coronaries are same. Likewise no two grafting are same. Accordingly no two patients would have same postoperative course. Hence there should be no slackness on the part of the team thinking that it is just a straight forward case and we can relax. We have always found that we make mistakes when we are not agile or when we take things for granted. As every patient is important. Hence, we should care for him like we care for our parents or our colleague. Once we are able to achieve this, then success can

In this chapter, we would like to present our view on how we plan our surgical strategy. Starting from the type of surgery, which the patient is going to undergo, to the revascularisation techniques which we plan are going to be discussed here. As we said, every patient needs to have his surgery tailor made according to his specific needs. Our main aim is to perform complete revascularisation on all patients, then, the next priority is to perform the coronary bypass without using the heart lung machine. Then our priority is to use arterial grafts where ever possible. The use of left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is a rule or standard for all patients. We have noticed that as the LAD is the most important artery in the heart, if the LIMA remains patent over 10 years then it usually remains open for life [2]. The presence of nitric oxide in LIMA in fact does not allow any clot formation inside it and that even a small LIMA remains patent as long as the run off of the LAD is good. And that once we anastomose a LIMA to the LAD, then it is unlikely that the LAD distal to the anastomosis would develop atherosclerosis. This is because of the nitric oxide that is secreted from the LIMA which prevents the development of atherosclerosis being formed in that region. This is unlike in case of drug eluting stent where we see narrowing of the vessel

Preparation of patients in OPCAB is rather less cumbersome than in patients with on-pump CABG. That is, we do not have to stop the antiplatelet medication in patients who are going to undergo OPCAB. Hence in patients with acute coronary syndrome we have the advantage of continuing the antiplatelet and the injection heparin till the day of surgery. Thereby avoiding ischemia in these patients. The only medicine we stop is beta blockers on the day of surgery. As we do not wish to reduce the heart rates unlike in other centres, we in fact like to increase the heart rate so as to increase the cardiac output in turn. This is how we are able to avoid the use of inotropes in all our patients during the positioning of the heart before grafting [1]. Apart from this there are no changes in the management of patients in

Anaesthetic management of patient being induced for OPCAB is similar in line,

as for all cardiac surgical patients, except that they are not totally ironed out.

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Once the patient is positioned, painted and draped (**Figures 1** and **2**).

The idea is to harvest the arterial grafts first and then the vein graft if necessary. The skin incision extends from 2 cm below the sternal notch to 1 cm above the xiphoid process. We usually dissect the xiphoid process out from both sides and its attachment below from the diaphragm using diathermy (which is at 70 coagulation and zero on the cutting—that is our setting on the diathermy). Hence the sternotomy starts by cutting the xiphoid out first and then starting the sternotomy as usual. The chest is opened as usual and the pericardium is slit longitudinally to expose the heart. The pericardium near the diaphragm is cut along the diaphragm up to the inferior vena cava (IVC). This is done after the right pleura is opened and the thymus is tied up near the superior vena cava (SVC). This helps in allowing the heart to lie freely when the heart is being positioned during grafting of the lateral wall vessels.

It is very important to maintain strict haemostasis all through the opening of the sternum till grafting at least—as all these patients are on antiplatelet medications and/or on heparin, so any bleeding site left unattended at this stage would cause unnecessary blood loss (photo of chest opened before harvesting the mammary). Hence, if we spend time for haemostasis during opening of the chest, then the closing becomes easy and tidy.

**Figure 1.** *Patient on the table with left arm on the side for radial artery harvesting.*

#### **Figure 2.**

*Shows the patient after draping and the surgery in progress, with chest being opened and the radial artery being harvested simultaneously.*

#### **Figure 3.** *Shows the IMA retractor in position.*

#### **5.2 Harvesting the LIMA**

The internal mammary artery (IMA) of the left side is the most important artery and that we need to harvest it with caution. And it is important to maintain hemodynamic all through this dissection, so that we can do a good job, as it is important to remember that the patient's longevity depends on the patency of LIMA anastomosis being patent all through. Earlier we used to dissect the LIMA as a pedicle, but for the last 2 years we have mastered this technique of Skeletonised mammary dissection, with a cold cautery technique, which does not allow the

**95**

**Figure 4.**

*Shows skeletonised LIMA after dissection.*

*Revascularisation Strategies in OPCAB (Off Pump Coronary Artery Bypass)*

LIMA to go into spasm during the harvesting. The cautery is usually set at 40 coagulation and no cutting during the mammary harvesting. The blood pressure is maintained at a systolic blood pressure between 130 and 140 mm during the dissection, so that we have a good pressure head and the mammary pulsates during

After the lift sternum is lifted (IMA retractor in position **Figure 3**).

The left pleura is opened longitudinally parallel to the sternum up to the top, after the branches crossing it are clipped and cut with a forehand scissors. The LIMA dissection starts from the xiphoid region. The Thoracic fascia is dissected using the diathermy by making a parallel incision on it medial to the LIMA all along the sternal edge. Then the cautery tip is now used as a cold cautery for all the dissections from now on. The tip is used to dissect the LIMA away from the thoracic fascia by moving the tip upward towards the LIMA and then used the tip on the diathermy to push the tissues up and away from the LIMA again, pushing the LIMA down from the chest wall to expose the intercostal branches, would cause avulsion of these branches at its base, which would end up in dissection of the LIMA. Once the distal end is dissected at the LIMA bifurcation, the two branches are clipped using two clips on the distal end and one liga clip on the proximal end, and then cutting it with the forward cutting Castroviejo scissors. At this stage no heparin is given. Dilute injection Papaverine is sprayed on the dissected end and the dissection is continued all through till the first branch of LIMA

In fact the IMA does not clot as its wall exudes nitric oxide and because it is clipped at the end and the blood pressure is maintained above 130 mm systolic it gets bigger by the time the dissection is over. The video of skeletonised LIMA is seen in the following link; SKELTONISED LIMA DISSECTION USING COLD

Once LIMA is dissected, then RIMA is also dissected depending on the revascu-

Simultaneously, the radial artery from the left hand is harvested. This is also taken down as a skeletonised artery and it is dilated with injection papaverine, which is injected intraluminally and clipped at end and stored in warm heparinised saline in a bowl. The important point to make sure in patients whose radial artery is harvested is to make sure that the pulse-oxymeter saturation of the thumb should always show the wave form and that it should be 100% at any given time. The arm has to be closed only after perfect haemostasis, and to make sure that the

CAUTERY TECHNIQUE. https://youtu.be/m7mYWLQsDAE.

*DOI: http://dx.doi.org/10.5772/intechopen.88102*

the dissection.

(LIMA dissection **Figure 4**).

larisation strategy.

LIMA to go into spasm during the harvesting. The cautery is usually set at 40 coagulation and no cutting during the mammary harvesting. The blood pressure is maintained at a systolic blood pressure between 130 and 140 mm during the dissection, so that we have a good pressure head and the mammary pulsates during the dissection.

After the lift sternum is lifted (IMA retractor in position **Figure 3**).

The left pleura is opened longitudinally parallel to the sternum up to the top, after the branches crossing it are clipped and cut with a forehand scissors. The LIMA dissection starts from the xiphoid region. The Thoracic fascia is dissected using the diathermy by making a parallel incision on it medial to the LIMA all along the sternal edge. Then the cautery tip is now used as a cold cautery for all the dissections from now on. The tip is used to dissect the LIMA away from the thoracic fascia by moving the tip upward towards the LIMA and then used the tip on the diathermy to push the tissues up and away from the LIMA again, pushing the LIMA down from the chest wall to expose the intercostal branches, would cause avulsion of these branches at its base, which would end up in dissection of the LIMA. Once the distal end is dissected at the LIMA bifurcation, the two branches are clipped using two clips on the distal end and one liga clip on the proximal end, and then cutting it with the forward cutting Castroviejo scissors. At this stage no heparin is given. Dilute injection Papaverine is sprayed on the dissected end and the dissection is continued all through till the first branch of LIMA (LIMA dissection **Figure 4**).

In fact the IMA does not clot as its wall exudes nitric oxide and because it is clipped at the end and the blood pressure is maintained above 130 mm systolic it gets bigger by the time the dissection is over. The video of skeletonised LIMA is seen in the following link; SKELTONISED LIMA DISSECTION USING COLD CAUTERY TECHNIQUE. https://youtu.be/m7mYWLQsDAE.

Once LIMA is dissected, then RIMA is also dissected depending on the revascularisation strategy.

Simultaneously, the radial artery from the left hand is harvested. This is also taken down as a skeletonised artery and it is dilated with injection papaverine, which is injected intraluminally and clipped at end and stored in warm heparinised saline in a bowl. The important point to make sure in patients whose radial artery is harvested is to make sure that the pulse-oxymeter saturation of the thumb should always show the wave form and that it should be 100% at any given time. The arm has to be closed only after perfect haemostasis, and to make sure that the

**Figure 4.** *Shows skeletonised LIMA after dissection.*

*Cardiac Surgery Procedures*

**Figure 2.**

*harvested simultaneously.*

**94**

**Figure 3.**

**5.2 Harvesting the LIMA**

*Shows the IMA retractor in position.*

The internal mammary artery (IMA) of the left side is the most important artery and that we need to harvest it with caution. And it is important to maintain hemodynamic all through this dissection, so that we can do a good job, as it is important to remember that the patient's longevity depends on the patency of LIMA anastomosis being patent all through. Earlier we used to dissect the LIMA as a pedicle, but for the last 2 years we have mastered this technique of Skeletonised mammary dissection, with a cold cautery technique, which does not allow the

*Shows the patient after draping and the surgery in progress, with chest being opened and the radial artery being* 

**Figure 5.** *Showing skeletonised radial artery.*

**Figure 6.** *Showing the haemostasis in the forearm after the radial artery is harvested.*

crepe bandage applied is not too tight. We do not use any specific vasodilators like nitroglycerin or post-operative Diltiazem, as we make sure that the Radial artery is grafted only on coronaries with more than 80% lesions for sure (**Figure 5**, showing the skeletonised radial artery) (**Figure 6**).

The radial artery dissection video is seen in the following link: https://youtu. be/19YY37hpeTs—radial artery dissection.

**97**

**Figure 10.**

**Figure 8.**

**Figure 9.**

*Showing EVH being done.*

*Revascularisation Strategies in OPCAB (Off Pump Coronary Artery Bypass)*

*DOI: http://dx.doi.org/10.5772/intechopen.88102*

*Showing the skip incisions on the lower limb after closing with clips.*

*Showing the single small scar after EVH technique… but this comes with a cost.*

**Figure 7.** *Showing the skip technique of SVG being harvested.*

*Revascularisation Strategies in OPCAB (Off Pump Coronary Artery Bypass) DOI: http://dx.doi.org/10.5772/intechopen.88102*

#### **Figure 8.**

*Cardiac Surgery Procedures*

**Figure 5.**

**Figure 6.**

*Showing skeletonised radial artery.*

**96**

**Figure 7.**

*Showing the skip technique of SVG being harvested.*

the skeletonised radial artery) (**Figure 6**).

*Showing the haemostasis in the forearm after the radial artery is harvested.*

be/19YY37hpeTs—radial artery dissection.

crepe bandage applied is not too tight. We do not use any specific vasodilators like nitroglycerin or post-operative Diltiazem, as we make sure that the Radial artery is grafted only on coronaries with more than 80% lesions for sure (**Figure 5**, showing

The radial artery dissection video is seen in the following link: https://youtu.

*Showing the skip incisions on the lower limb after closing with clips.*

**Figure 9.** *Showing EVH being done.*

**Figure 10.** *Showing the single small scar after EVH technique… but this comes with a cost.*

The third conduit that is harvested is usually the long saphenous vein (SVG). It is either harvested from the thigh or from the leg. It is dissected as an open technique or by a skip technique (**Figures 7** and **8**), showing the skip technique of SVG being harvested (avoiding a continuous incision and the wound afterward) which does not need any extra instrumentation.

The other technique is to use endoscopic vein harvesting technique (EVH) **Figures 9** and **10**.
