Technique and results with side-to-side anastomoses

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The technique that we have used exclusively for multiple vein graft procedures during the past 5 years consists of an end-to-side anastomosis of the vein to a coronary branch, coiling the vein around the heart with a side-to-side anastomosis at each target coronary, and ending with the aortic anastomosis. This has been referred to as the “snake graft.”

The end of the vein is cut in an S-shaped manner and sutures are usually placed on opposite sides of the resulting oval, rather than at the tip and the throat. All coronary anastomoses are done with 6-0 Prolene by tying at one end of the coronary incision, doing all of one side and half the other with one needle, and the remaining quarter with the other. For multiple grafting on the diaphragmatic surface, the vein is incised transversely. It is important that this be less than one third the circumference of the vein.

The myocardium is protected by clamping the aorta, pouring cold solution in the pericardium, and temporarily filling the left ventricle with cold solution through the apical vent. After each coronary anastomosis, the ventricular cavity is refilled. This expands the heart to its maximum diastolic dimensions and permits an accurate estimate of the length of vein segments, which is critical.

Usually a direct route is chosen from one anastomosis to the next. An exception is the route from the anterior descending to a diagonal branch from the anterior approach. Here a gentle curve is permitted to prevent angulation at . . .



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