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Anaortic, off-pump coronary artery bypass using multiple arterial grafts: Surgical technique

Traditional on-pump coronary artery bypass grafting on an arrested heart using a single arterial graft carries 2 main potential drawbacks: the risk of perioperative neurological injury and the known failure rate of vein grafts. To address this, we describe a surgical technique of anaortic, off-pump coronary artery bypass that avoids all manipulation of the ascending aorta and uses multiple-arterial grafts to achieve complete revascularisation. This provides optimal short- and long-term outcomes and is particularly important in high-risk subgroups. The standard graft configuration is the left internal mammary artery to the anterior wall, and the right internal mammary artery is extended with the radial artery and brought through the transverse sinus to revascularise the lateral and inferior walls sequentially. Alternative configurations, including “T” grafts and using long saphenous vein, are considered if patients have factors limiting arterial conduit selection. Arterial conduits are harvested using a skeletonised technique. The radial artery may also be harvested endoscopically. Wide, bilateral retrothymic tunnels are formed for the internal mammary arteries. The pericardium is opened using specific incisions designed to facilitate positioning of the heart whilst maintaining venous return and cardiac output. There are 4 main positions for the heart during grafts (high-lateral wall, low-lateral wall, inferior wall and anterior wall). These are obtained using a combination of table position, wet sponges, two nylon sutures placed in the pericardium and the off-pump stabiliser. All distal anastomoses are performed using homemade intra-coronary silastic shunts, which provide optimal grafting conditions. Graft patency is confirmed using transit-flow time measurement.


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