**6.1 On-pump CABG technique**


• Graft is distended with blood cardioplegic solution, graft lie is checked, and

• The heart is then retracted to the right and then OM is selected for grafting.

• LIMA-LAD anastomosis is created with Polypropylene 7-0 or 8-0 sutures

• Partially occluding clamp is applied on the ascending aorta (**Figure 13**).

• Proximal anastomosis is done between the aorta and grafts with Prolene 6-0

• Two to three openings are made in the aorta using aortic punch.

• Graft is distended with solution and appropriate length divided.

appropriate length is divided.

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

• LIMA is cut to appropriate length.

• Phrenic nerve should not be injured.

• Partially occluding clamp is removed.

• De-airing of the grafts is done.

• Aortic cross clamp is removed.

(**Figure 12**).

sutures.

**Figure 12.**

**93**

*LIMA-LAD anastomosis.*

• Distal anastomosis is done to selected OM vessel.

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

• The same technique is used for diagonal anastomosis.

• Then focus is changed to LIMA-LAD anastomosis.

• Rewarming is started while doing anastomosis.

• A pericardial window is made to pass LIMA without tension.

#### **Figure 10.** *Cannulation for on-pump CABG.*


**Figure 11.** *SVG-coronary artery anastomosis.*

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


**Figure 12.** *LIMA-LAD anastomosis.*

• Epiaortic ultrasound can be used to find the site devoid of calcification or

• The heart is retracted out of the pericardial cavity, toward the head of the

atherosclerotic plaques, for cannulation [13].

*The Current Perspectives on Coronary Artery Bypass Grafting*

patient.

**Figure 11.**

**92**

*SVG-coronary artery anastomosis.*

**Figure 10.**

*Cannulation for on-pump CABG.*

• Aorta is cross clamped and antegrade cardioplegia given.

• Usually first distal graft is done to RCA or PDA (**Figure 11**).

• Cold saline or ice slush can be used for topical cooling.

• Hemodynamically unstable patients

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

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

*6.2.1.2 Experienced beating heart surgeons*

**OPCAB is particularly beneficial for:**

Majority of the cases can be performed without complication after getting a good

experience in off-pump CABG, but it is better to avoid if multiple unfavorable factors are present in the same patient (cardiomegaly with EF <25% and small

• Critical left main disease

• Recent acute MI

• High-risk patients

• High calcific load

• Diabetes mellitus

• Renal failure

• Reoperations

**6.3 Contraindications**

*6.3.1 Absolute contraindications*

• Deep myocardial LAD

*6.3.2 Relative contraindications*

**95**

• Pulmonary hypertension

• Diffuse coronary artery disease

• Left ventricle dysfunction

• Age older than 75 years

• Left main stem disease

• Chronic pulmonary disease

• An overall EuroSCORE >5 [15, 16]

• Preoperative hemodynamic instability

• Moderate to severe mitral regurgitation

• Dense myocardial adhesions during reoperative surgery

• LV EF <35%

vessels).

**Figure 13.** *Side-biting clamp on the ascending aorta for proximal anastomosis.*

