Coronary arteriotomy is utilized for coronary artery bypass grafting or, less frequently, coronary endarterectomy. The site of the arteriotomy is primarily dictated by the location of the stenotic or occlusive lesion, which can be determined by preoperative imaging in conjunction with manual intraoperative palpation. In general, ideal arteriotomy sites are distal to the stenosis or occlusion, epicardial, and devoid of tortuosity or gross disease.
The circumference and geometry of the arteriotomy should correspond to bypass conduit measurements, ie, small and large conduit lumens necessitate small and large arteriotomies, respectively. The bypass conduit should be distended during these measurements to simulate in vivo dimensions. A fresh #15C scalpel blade should be utilized for each separate arteriotomy, and cardiac movement should be minimized during all incisions. The scalpel blade is positioned at a 45-degree angle to the tangent of the vessel circumference, and a longitudinal incision is made at the vessel midline. Coronary probes can be used to confirm entrance into the vessel lumen. The arteriotomy is then extended proximally and distally to accommodate the bypass conduit measurements. Although complications are rare during coronary arteriotomies, care must be taken to avoid coronary artery dissection as well as perforation of the posterior vessel wall.
Suggested Reading
- Alexander JH, Smith PK. Coronary-artery bypass grafting. N Engl J Med. 2016;374(20):1954-1964.
- Martinez-Gonzalez B, Reyes-Hernandez CG, Quiroga-Garza A, et al. Conduits used in coronary artery bypass grafting: a review of morphological studies. Ann Thorac Cardiovasc Surg. 2017;23(2):55-65.
- Ischemic Heart Disease. In: Chikwe J, Cooke DT, Weiss A. Cardiothoracic Surgery (Oxford Specialist Handbooks in Surgery). 2nd ed. Oxford, England: Oxford University Press; 2013: 324-335.
- Ischemic Heart Disease. In: Doty DB, Doty JR. Cardiac Surgery: Operative Technique. 2nd ed. Philadelphia, PA: Saunders, an imprint of Elsevier; 2012: 393-431.
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1 Comment
I congratulate the authors on this contribution focusing on the importance of this seemingly mundane but crucial element in quality CABG surgery.
I have several additional fine points that I hope others may find helpful:
1. Always look for the purple stripe(if blood cardioplegia is used) if possible, and avoid nearby plaques
2. Shut off the vent prior to arteriotomy to distend the coronary artery , and turn it back on once open.
3.Make sure a little blood comes out. If it doesn’t, you may not yet be fully in the lumen.
4.I have usually preferred using a fine pointed Beaver blade with the sharp end up and inserted at an acute angle and have found this technique less apt to injure the back wall. Additionally, this technique typically allows for a smaller arteriotomy whereas the 15 blade created arteriotomy is typically longer, but works well for large distal RCA vessels.
5.Once I have created a good clean distal end of the arteriotomy, I try to avoid , if possible, lengthening it distally as the resultant cut may not be as clean and thus will tend to just extend it proximally if needed where it is typically not as crucial.
6. I try to limit the use of probes as much as possible and feel that they can cause intimal injury and spasm.
7. It is not clear that the arteriotomy has to be tailored to the size of the distended conduit. It may be better to have it distend after anastamosis to a slightly smaller arteriotomy giving a better “cobra-head” appearance.