Total-arterial, anaortic, off-pump coronary artery bypass grafting-surgical technique

Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein, carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total-arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral, and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and nondominant radial artery are harvested using a fully skeletonized technique. Wide bilateral extrapleural retrothymic tunnels are developed, and the pericardium is opened widely to facilitate cardiac positioning. An in situ right internal mammary artery-radial artery tandem graft is constructed using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The in situ left internal mammary artery is used to graft the anterior wall.