**4.2 Indications for CABG**



**Table 1.**

*Classification of indications for CABG surgery.*


• Right gastroepiploic artery

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

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

• Inferior epigastric artery

• Greater saphenous vein

• Short saphenous vein

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

the implant and the coronary arteries, but few surgeons took their work

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

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

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.

• Ulnar artery

• Splenic artery

**5.2 Venous grafts**

• Cephalic vein

**5.3 Arterial grafts**

seriously [11].

for grafting.

**85**

*5.3.2 Radial artery*


### **4.3 Contraindications**

*4.3.1 Absolute contraindication*

There is no absolute contraindication.

	- 1.Asymptomatic patient with low risk of MI or death.
	- 2.Advanced age.
	- 3.Co-morbidities (COPD, pulmonary hypertension, etc.)

#### **4.4 Factors increasing mortality after CABG**

