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Anterior wall revascularization
SOP » Surgery protocol » Anterior wall revascularization
Last modified on Tue 15 Jul 2014

The exposure of the LAD is accomplished by placing a horizontal line of interrupted silk sutures along the left side of the pericardium, as low as possible without touching the heart. This manoeuvre alone should expose the LAD and diagonal vessels in virtually all cases. When visualization of the diagonals is insufficient, the enucleation is performed first (see below).
Anastomoses to the diagonal are performed first only when sequenced to the LAD with the IMA. In all other circumstances, the LAD is grafted first .
The suction stabilizer is then attached to the sternal retractor in the right lower position. With the stabilizer clamped in the right lower position its arms will be pointing in the opposite direction of flow in the LAD.
This allows an unobstructed approach of the graft towards the anastomotic target. The malleable arms of the device are shaped to allow optimal stabilization of the LAD while requiring less suction and placing less pressure on the cardiac surface.
The stabilizer is transformed by enlarging the space between the arms, rotating or bending the arms. The holes can be occluded with bone wax to avoid suction on top of side branches. The coronary vessel is then dissected and explored. The use of everting traction sutures exposes and further stabilizes the target vessel.

The anastomotic region is surveyed in the usual fashion and an estimation of the internal diameter is made so that a proper size shunt is chosen. Strict attention is paid to proximal disease and side branches. This information will determine which direction the long end of the shunt will point, so as to avoid obstructing a side branch or creating selective perfusion. If necessary, the longest section is directed toward a tortuous vessel to straighten it and ensure flow.
A 4.0 prolene suture on a 1808 needle with a soft tourniquet is placed around the coronary vessel proximal to the grafting site. If the coronary artery has an intramural or intraseptal pathway, the risk of injuring the vessel is increased and this suture is then omitted.
The vessel is incised normally using a full set of arteriotomy scissors covering all possible angulations. The tourniquet is then gently tightened to allow a clear bloodless field while placing the shunt. The longest section of the shunt is inserted (towards whatever direction is optimal for that anastomosis) first, the tourniquet is partially released to identify intra-luminal position. The short end is then inserted in a ‘goose-neck’ fashion. The tourniquet is completely released and removed. The distal coronary perfusion area is then inspected for colour and contractility.

A shunt is no guarantee of sufficient perfusion.

Fig. 4 : The flow through a 2 mm shunt (Heart Surgery Forum 2003; 7(1):E8)

As such, anesthesia will closely monitor the markers of ischemia and correct by increasing volume, administering selective vasoconstrictors or giving vasodilating agents. If ischemic changes occur, the surgeon is obligated to re-inspect the size and the pathway of the selected shunt.

The anastomosis is created by first placing a mattress stitch in the heel of the graft and then approximating it immediately to the vessel. The anastomosis is completed with the graft down on the target vessel. As a rule, the graft is not parachuted since it would later become difficult when grafting an obtuse marginal (OM) where there is little space to manoeuvre. For the sake of training, routine and speed, all anastomoses are created in an identical fashion.