The 10 Commandments for Proximal Anastomosis During CABG: Techniques and Technologies for Vein and Arterial Grafts

This article examines the critical role of proximal anastomosis in coronary artery bypass grafting (CABG), highlighting its impact on the risk of perioperative stroke. Key points include the importance of thorough preoperative assessments, particularly using CT scans to evaluate ascending aorta calcification, a known risk factor for stroke. Intraoperative epiaortic ultrasound is emphasized as a superior method for assessing aortic condition and guiding surgical strategy, thus reducing stroke risk. The article also advocates for anaortic revascularization techniques to minimize aortic manipulation, which is associated with higher stroke rates. Devices such as Heartstring, Enclose II, and Viola are introduced as alternatives to traditional side-clamping methods, allowing safer proximal anastomoses with less aortic contact. Additionally, the piggyback anastomosis technique is recommended for multivessel surgery to reduce aortic invasiveness. The article also explores alternative sites for proximal anastomosis, such as the axillary and innominate arteries, especially when traditional methods are not suitable. The authors stress the importance of graft assessment using transit time flow measurement (TTFM) to ensure optimal graft function and emphasize meticulous planning regarding graft length and orientation to prevent complications. Finally, the use of radio markers to mark anastomosis sites is suggested to aid future interventions.