**5. Types of grafts**

### **5.1 Arterial grafts**


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


3. Symptomatic double- or triple-vessel disease.

*The Current Perspectives on Coronary Artery Bypass Grafting*

5.Poor LV functions.

9.Emergency CABG.

*4.3.1 Absolute contraindication*

*4.3.2 Relative contraindications*

There is no absolute contraindication.

**4.4 Factors increasing mortality after CABG**

1.Preoperative renal insufficiency.

2.Peripheral vascular disease.

1.Asymptomatic patient with low risk of MI or death.

3.Co-morbidities (COPD, pulmonary hypertension, etc.)

• Internal thoracic artery (internal mammary artery)

6.Post MI angina.

or PCI.

10.Failed PCI.

**4.3 Contraindications**

2.Advanced age.

3.Recent MI.

4.Recent brain stroke.

5.Emergency surgery.

6.Cardiogenic shock.

**5. Types of grafts**

**5.1 Arterial grafts**

• Radial artery

**84**

4.Disabling angina despite maximal medical therapy.

7.Post NSTEMI with ongoing ischemia that is unresponsive to medical therapy

8. STEMI with inadequate response to all nonsurgical management.

• Splenic artery

#### **5.2 Venous grafts**


#### **5.3 Arterial grafts**

#### *5.3.1 Left internal mammary artery (LIMA)/left internal thoracic artery (LITA)*

Drs. Vineberg and Miller were the first to recognize the properties of internal mammary artery (IMA) and used it for myocardial revascularization in 1945 [10]. They found that it is usually spared from atherosclerosis and reasoned that its branches could form collaterals with myocardial arterioles. They injected contrast medium in postmortem specimens demonstrating connections between the implant and the coronary arteries, but few surgeons took their work seriously [11].

LIMA originates from subclavian artery just above and behind the sternal end of the clavicle (**Figure 2**). The artery descends vertically 1 cm lateral to the sternal border, behind the first six costal cartilages. **Figure 3** shows the LIMA position regarding pectoralis muscle, sternum, and pleura with endothoracic fascia. LIMA is widely used these days, especially for the anastomosis with LAD. After dividing the sternum, retractor is placed to lift the left sterna edge. The operating table can be elevated and rotated to expose LIMA properly and harvest it. LIMA can be harvested as pedicle graft (along with internal thoracic veins, fat, muscles, and pleura) or skeletonized vessel. Skeletonized LIMA is supposed to preserve the venous drainage of the sternum, and it is often preferred when there is suspicion of sternal healing and wound infection. All small branches of LIMA are clipped. The proximal end of the LIMA kept attached to the subclavian artery, and then after giving heparin, the distal end is ligated and divided. In the same way as LIMA is harvested, RIMA can also be harvested if it is needed for grafting.

#### *5.3.2 Radial artery*

The second most commonly used artery is the radial artery (RA). It is usually harvested from nondominant hand (**Figure 4**). The RA arises from the bifurcation of the brachial artery in the cubital fossa and terminates by forming the deep palmar arch in the hand. The main concern using RA is blood supply to the wrist and hand. Before using the radial artery, we should assess the patency and collateral blood circulation from the ulnar artery. It can be assessed clinically by Allen's and modified Allen's tests. This can also be assessed by preoperative arterial ultrasound.

*The Current Perspectives on Coronary Artery Bypass Grafting*

*5.3.3 Right gastroepiploic artery*

*Radial artery and palmer arch.*

**Figure 4.**

**Figure 5.**

**87**

*Gastroepiploic artery.*

It is very rarely used as an arterial graft when other conduits are not available. To harvest this artery, the midline incision over the sternum is extended to the upper abdomen, and the abdominal cavity is opened. There are two gastroepiploic arteries (**Figure 5**): left and right. Both arteries participate in the stomach vascularization and are collateral blood circulation with other blood vessels of the stomach. Harvesting right gastroepiploic artery as conduit does not compromise stomach blood supply. Branches of this artery to the stomach and omentum are ligated and divided. This artery is positioned either anteriorly or posteriorly to the duodenum

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

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

**Figure 2.** *Internal mammary artery course.*

*Relationship of LIMA with sternum, thoracic muscles, pleura, and endothoracic fascia.*

The radial artery can be harvested by open conventional method or endoscopically. The radial artery should be flushed and kept in a solution prepared with Ringer lactate (500 ml), sodium nitroprusside (50 mg), and heparinized blood (30 ml).

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

**Figure 4.** *Radial artery and palmer arch.*
