**6.4 Operative steps**


• Most of the surgeons usually do distal anastomoses first, but proximal

length, whereas performing them first allows immediate myocardial

• Positioning the heart is very important and needs mechanical stabilizers as

• **Anterior wall vessel anastomosis**—anterior wall vessels (LAD, diagonal, ramus) need to be brought near midline for better visualization and anastomosis. Deep pericardial retraction sutures of silk, vicryl, or ethibond (1-0) should be taken fast near the left superior pulmonary vein in order to

• **Inferior wall vessel anastomosis**—for distal right coronary artery and posterior descending artery, the table is in steep Trendelenburg position. Manipulation of the deep pericardial retraction sutures is done to better expose the grafting vessel. For grafting the right coronary artery, the table is made flat,

and retraction sutures are relaxed with the heart failing to the left side. Maneuvering the heart for RCA and PDA grafting can cause bradycardia and hypotension, so anesthetists should be more vigilant and need to give fluid and

• **Lateral wall vessel anastomosis**—for obtuse marginals, posterolateral branches of the right coronary artery, the OR table is placed in steep Trendelenburg position, raised and rotated toward the right [17]. This will allow gravity to displace the heart to the right and apex anteriorly. The right pleura is opened, and the right pericardial incision is extended toward the inferior vena cava, so that the heart can be displaced toward the right side without hemodynamic compromise. Some extra deep pericardial retraction sutures may need to be taken between the inferior vena cava and pulmonary vein. The first suture is anchored just above the left superior pulmonary vein, the second below the left inferior pulmonary vein, the third one called "the intermediate" is located between the inferior pulmonary vein and the inferior vena cava, and the fourth one close to the inferior vena cava. These stitches are quite comparable to the "Lima Stitches" introduced in North America in 1997

• Do not compromise the exposure, and if it is not possible, then convert to

• A silastic tape or vascular sling is passed around the selected coronary artery

• Blower is used selectively when needed and at a rate not >5 L/min to prevent

• A CO2 blower is used to disperse the blood to create the anastomosis.

inotropes to keep hemodynamic stability during grafting.

• Performing proximal aortic anastomoses last allows precise estimation of graft

anastomoses can be done before distal anastomoses.

*Coronary Artery Bypass Grafting: Surgical Anastomosis: Tips and Tricks*

reperfusion once each distal anastomosis is completed.

octopus and starfish.

by Tom Salerno [18].

endothelial damage.

**97**

conventional on-pump CABG.

proximal to the site chosen for anastomosis.

• Intracoronary shunts are inserted in coronary arteriotomy.

prevent hemodynamic instability.

*DOI: http://dx.doi.org/10.5772/intechopen.88932*


**Figure 14.** *OPCABG setup: octopus and starfish.*

*Coronary Artery Bypass Grafting: Surgical Anastomosis: Tips and Tricks DOI: http://dx.doi.org/10.5772/intechopen.88932*


• Enlarged ascending aorta

• No need to prime the CPB machine.

also be available (**Figure 14**).

**6.4 Operative steps**

grafting.

vessels).

**Figure 14.**

**96**

*OPCABG setup: octopus and starfish.*

• Midline sternotomy.

• LM disease with a non-reconstructable RCA system

*The Current Perspectives on Coronary Artery Bypass Grafting*

• Preserve normothermia by keeping the operating room warm.

• Off-pump setup (octopus, starfish, CO2 blower, intracoronary shunts) should

• Maintaining the systolic BP is important during positioning of the heart for

• CPB machine and perfusionist should be available in OR.

• Inotropic supports and IV fluid is usually required.

• Heparin is given (1–1.5 mg/Kg) to keep ACT of about 300 s.

• ACT should be checked every 20 min and added as required.

• Coronary arteries should be grafted in the order of increasing cardiac

displacement (anterior wall vessels, then inferior wall, and finally lateral wall

• LIMA and other conduits are harvested.

• A temporary pacing wire can be placed for anastomosis to RCA to combat the bradycardia.

• The most stenotic vessel is always revascularized first because this vessel is

anastomosis of the same graft is completed before proceeding to the next distal

• The ascending aorta is side clamp only once during the procedure to minimize

• The systemic pressure is always reduced around 90–100 mmHg before and

• The anterior and the inferior territories are always grafted before the posterior

The sequential bypass graft is an effective multiple-bypass technique when graft availability is limited [19] and has been reported to allow improved rates of patency in bypass procedures on narrow coronary arteries [20, 21]. Compared with regular end-to-side anastomosis, however, side-to-side anastomosis is a relatively complex

1.A diamond configuration, in which the graft axis lies perpendicular to the axis of the target coronary vessel (crossed side-to-side anastomosis) (**Figure 15**)

• The proximal anastomosis of the graft is performed just after the distal

• Intracoronary shunts are used to prevent ischemia.

*Coronary Artery Bypass Grafting: Surgical Anastomosis: Tips and Tricks*

during the entire side clamping of the ascending aorta.

Methods of side-to-side anastomosis include the following:

normally well collateralized.

*DOI: http://dx.doi.org/10.5772/intechopen.88932*

anastomosis.

the aortic trauma.

**6.7 Sequential bypass grafting**

territory.

procedure.

**Figure 15.**

**99**

*Crossed side-to-side anastomosis.*

