**5.3 Grafting sequence**

The first artery to be grafted is usually the LAD (left anterior descending), and always by LIMA unless there is an issue. This is the link that shows our grafting pattern.

The video link of the play list is: https://www.youtube.com/playlist?list=PLmvb6 npEfabinhlatq8IYLBz8WlHo8bu1.

In case there is an issue with the LIMA, like it is short, due to dissection or injury, either we use the R(right)IMA (**Figure 11**, RIMA to LAD) or the radial artery or the vein piece hocked to the LIMA to reach the LAD.

This link shows: LIMA TO RADIAL ANASTAMOSED TO LAD, DIAGONAL AND MARG CIRC as a 'C' graft: https://youtu.be/OaOjXlRk7Nk.

Sometimes when we use RIMA to LAD, if it is long enough, then we use LIMA to radial and skip to all the coronaries. If we plan for a total arterial grafting, the preference is to have two inflows to the coronaries if both the left and the right coronary artery need grafting. But if it is only the left system that need grafting and if we plan for a total arterial grafting with no touch technique of the aorta, then LIMA—RIMA Y or LIMA—radial Y is used.

Video links showing:

BIMA-LIMA TO DIAGONAL AND LAD. RIMA TO RADIAL SKIP TO PDA AND PLV: https://youtu.be/96LLBz1hS5k.

BIMA-LIMA TO DIAGONAL-LAD.RIMA TO RADIAL SKIP TO RAMOS, OM & PDA: https://youtu.be/fJ\_kLZmQV6I.

BIMA-LIMA TO DIAGONAL AND LAD. RIMA TO RADIAL SKIP TO OM & PDA: https://youtu.be/SN1F8YjPiUA

**99**

**Figure 14.**

*Shows the VAO (Vettath's anastomotic obturator).*

**Figure 12.**

**Figure 13.**

*Shows LIMA—radial Y graft.*

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

*Shows the usual OPCAB × 5 (LIMA to diagonal skip to LAD and SVG to OM1, OM2 and PDA).*

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

**Figure 11.** *Shows RIMA anastomosed to LAD.*

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

#### **Figure 12.**

*Cardiac Surgery Procedures*

**Figures 9** and **10**.

**5.3 Grafting sequence**

does not need any extra instrumentation.

npEfabinhlatq8IYLBz8WlHo8bu1.

LIMA—RIMA Y or LIMA—radial Y is used.

AND PLV: https://youtu.be/96LLBz1hS5k.

PDA: https://youtu.be/fJ\_kLZmQV6I.

PDA: https://youtu.be/SN1F8YjPiUA

Video links showing:

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

The other technique is to use endoscopic vein harvesting technique (EVH)

The first artery to be grafted is usually the LAD (left anterior descending), and always by LIMA unless there is an issue. This is the link that shows our grafting pattern. The video link of the play list is: https://www.youtube.com/playlist?list=PLmvb6

In case there is an issue with the LIMA, like it is short, due to dissection or injury, either we use the R(right)IMA (**Figure 11**, RIMA to LAD) or the radial

This link shows: LIMA TO RADIAL ANASTAMOSED TO LAD, DIAGONAL

Sometimes when we use RIMA to LAD, if it is long enough, then we use LIMA to radial and skip to all the coronaries. If we plan for a total arterial grafting, the preference is to have two inflows to the coronaries if both the left and the right coronary artery need grafting. But if it is only the left system that need grafting and if we plan for a total arterial grafting with no touch technique of the aorta, then

BIMA-LIMA TO DIAGONAL AND LAD. RIMA TO RADIAL SKIP TO PDA

BIMA-LIMA TO DIAGONAL-LAD.RIMA TO RADIAL SKIP TO RAMOS, OM &

BIMA-LIMA TO DIAGONAL AND LAD. RIMA TO RADIAL SKIP TO OM &

artery or the vein piece hocked to the LIMA to reach the LAD.

AND MARG CIRC as a 'C' graft: https://youtu.be/OaOjXlRk7Nk.

**98**

**Figure 11.**

*Shows RIMA anastomosed to LAD.*

*Shows the usual OPCAB × 5 (LIMA to diagonal skip to LAD and SVG to OM1, OM2 and PDA).*

**Figure 13.** *Shows LIMA—radial Y graft.*

**Figure 14.** *Shows the VAO (Vettath's anastomotic obturator).*

BIMA and radial. LIMA TO LAD, LIMA-RADIAL TO DIAGONAL, RIMA TO RADIAL TO PDA: https://youtu.be/sWa2N3qlCm4.

Most of the elderly patients (above 75–80 years of age) we stick to LIMA and vein grafts.

(**Figure 12**), or LIMA—Radial Y if only left system is involved (**Figure 13**)

The only difference is that the vein grafts are connected to the aorta without using the side clamp. In such patients who has some island of soft aortic wall left, or if they have a patch of non-calcified aorta left, we use the VAO (Vettath's anastomotic obturator) (**Figure 14**, showing the VAO).

This is one of our earliest innovations, way back in 2004, which was published in HSF [3–5]. **Figure 15**, showing the vein graft being anastomosed to the aorta using VAO.

This is the video link of the VAO being used: https://youtu.be/10eNQbPhLR0.

Because of the increasing number of diabetic patients and patients with diffusely diseased coronary arteries and with increasing amount of patients undergoing triple vessel stenting, cardiac surgeons end up getting the worst set of patients who needs a CABG. Hence, in this scenario we had developed our own technique of mammary patch on diffusely diseased LAD without endarterectomy on beating heart [6, 7].

The link of the video showing mammary patch is as follows:

https://youtu.be/bLNj2Xfjt9w Mammary Patch using Aorto Coronary Shunt. https://youtu.be/vEQfIcsarG8 MAMMARY PATCH angioplasty using long intra coronary Shunt.

https://youtu.be/peoxcDu67m0 Long Mammary Patch angioplasty using Double Stabilizer.

It is very important to understand that when we do a mammary patch using the left IMA, then, this LIMA should never be shared with any other conduit. It should be dedicated only to the LAD.

In patients with buried coronary arteries, it is important to identify them using all the techniques we do while we are on pump, and use it in off pump. It is important to position the heart first so that it does not cause any hemodynamic compromise during stabilisation and grafting (video link as for SIMS). The LIMA stich, of putting a stay in the pericardium using a dexon stitch and lifting the pericardium

**101**

**Table 1.**

*Showing our OPCAB results.*

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

to expose the lateral wall of the heart without compromising the haemodynamics is

Usually in an ischaemic patient we notice that the ST segments go down by the time we are half way through the IMA dissection and then when the blood pressure drops, we end up putting the head end of the patient down, so as to increase the preload. When we do that, we see that the heart distends and the Pulmonary artery pressure goes up and then the patient becomes more ischaemic as his end diastolic pressure goes up and he develops sub-endocardial ischemia. In such patients irrespective of the systemic pressure its better off having the head end of the patient up, which empties the heart a bit and pulmonary artery pressure comes down and it is important to increase the heart rate so that it also helps in increasing stroke volume and the cardiac output. But in case that does not work, then we have to insert an IABP to salvage the situation. Because every patient who undergo OPCAB in our centre has two arterial lines, one in the Radial artery and another in the Femoral artery. The one in the femoral region is exchanged to an IABP using the Seldinger technique [8]. This has been a boon for us, as we are able to place the IABP immediately, and then go on with the grafting without going on the heart lung machine (HLM). Over the last 15 years we have noticed that we were able to remove the IABP from the patient after the grafting is complete and after reversal of heparin. This innovation has worked so far and we never had to reinsert one in the ICU again on

**From To OPCAB Conversion IABP removed in OT Mortality no** 01-2003 12-2003 177 12 0 0 01-2004 12-2004 238 6 0 1 01-2005 12-2005 299 0 0 3 01-2006 12-2006 284 0 4 5 01-2007 12-2007 260 1 8 0 01-2008 12-2008 225 0 11 2 01-2009 12-2009 280 0 8 0 01-2010 12-2010 358 0 22 0 01-2011 12-2011 413 0 24 0 01-2012 12-2012 425 0 23 2 01-2013 12-2013 429 0 18 2 01-2014 12-2014 312 0 6 3 01-2015 12-2015 317 0 6 2 01-2016 12-2016 228 0 11 3 01-2017 12-2017 109 0 0 0 01-2018 12-2018 196 0 0 0 **Total 4550 19 (0.4%) 144 (3.1) 20 (0.43%)**

In patients who are ischaemic and unstable with big lateral wall vessels which are tightly stenosed, or in patients with dilated myocardium or huge heart, we end up

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

using an intra-aortic balloon pump (IABP).

very useful to avoid conversions.

these patients (**Table 1**).

**OPCAB statistics**

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

*Cardiac Surgery Procedures*

vein grafts.

VAO.

heart [6, 7].

coronary Shunt.

be dedicated only to the LAD.

Stabilizer.

RADIAL TO PDA: https://youtu.be/sWa2N3qlCm4.

motic obturator) (**Figure 14**, showing the VAO).

BIMA and radial. LIMA TO LAD, LIMA-RADIAL TO DIAGONAL, RIMA TO

Most of the elderly patients (above 75–80 years of age) we stick to LIMA and

This is one of our earliest innovations, way back in 2004, which was published in HSF [3–5]. **Figure 15**, showing the vein graft being anastomosed to the aorta using

This is the video link of the VAO being used: https://youtu.be/10eNQbPhLR0. Because of the increasing number of diabetic patients and patients with diffusely diseased coronary arteries and with increasing amount of patients undergoing triple vessel stenting, cardiac surgeons end up getting the worst set of patients who needs a CABG. Hence, in this scenario we had developed our own technique of mammary patch on diffusely diseased LAD without endarterectomy on beating

https://youtu.be/bLNj2Xfjt9w Mammary Patch using Aorto Coronary Shunt. https://youtu.be/vEQfIcsarG8 MAMMARY PATCH angioplasty using long intra

https://youtu.be/peoxcDu67m0 Long Mammary Patch angioplasty using Double

It is very important to understand that when we do a mammary patch using the left IMA, then, this LIMA should never be shared with any other conduit. It should

In patients with buried coronary arteries, it is important to identify them using all the techniques we do while we are on pump, and use it in off pump. It is important to position the heart first so that it does not cause any hemodynamic compromise during stabilisation and grafting (video link as for SIMS). The LIMA stich, of putting a stay in the pericardium using a dexon stitch and lifting the pericardium

The link of the video showing mammary patch is as follows:

(**Figure 12**), or LIMA—Radial Y if only left system is involved (**Figure 13**) The only difference is that the vein grafts are connected to the aorta without using the side clamp. In such patients who has some island of soft aortic wall left, or if they have a patch of non-calcified aorta left, we use the VAO (Vettath's anasto-

**100**

**Figure 15.**

*Shows RIMA-radial to LAD, SVG to obtuse marginal artery, which is attached to aorta using the VAO.*

to expose the lateral wall of the heart without compromising the haemodynamics is very useful to avoid conversions.

In patients who are ischaemic and unstable with big lateral wall vessels which are tightly stenosed, or in patients with dilated myocardium or huge heart, we end up using an intra-aortic balloon pump (IABP).

Usually in an ischaemic patient we notice that the ST segments go down by the time we are half way through the IMA dissection and then when the blood pressure drops, we end up putting the head end of the patient down, so as to increase the preload. When we do that, we see that the heart distends and the Pulmonary artery pressure goes up and then the patient becomes more ischaemic as his end diastolic pressure goes up and he develops sub-endocardial ischemia. In such patients irrespective of the systemic pressure its better off having the head end of the patient up, which empties the heart a bit and pulmonary artery pressure comes down and it is important to increase the heart rate so that it also helps in increasing stroke volume and the cardiac output. But in case that does not work, then we have to insert an IABP to salvage the situation. Because every patient who undergo OPCAB in our centre has two arterial lines, one in the Radial artery and another in the Femoral artery. The one in the femoral region is exchanged to an IABP using the Seldinger technique [8]. This has been a boon for us, as we are able to place the IABP immediately, and then go on with the grafting without going on the heart lung machine (HLM).

Over the last 15 years we have noticed that we were able to remove the IABP from the patient after the grafting is complete and after reversal of heparin. This innovation has worked so far and we never had to reinsert one in the ICU again on these patients (**Table 1**).


#### **Table 1.** *Showing our OPCAB results.*

**Figure 16.** *Shows stabilizer with pods.*

**Figure 17.** *Shows combo device, which comes in a box.*
