How to construct the proximal anastomosis: tips, tricks and technique #proximalanastomosis

All proximal anastomoses that are done on cardiopulmonary bypass are either being performed with the aortic cross-clamp in place or after declamping the aorta. The first approach would have a significantly reduced rate of stroke as against the latter which allows the heart to recover from the cardioplegic arrest and beat normally whilst the proximal is being placed. With the heart being empty and flaccid whilst on CPB, estimating the correct length of the vein graft may be difficult and hence the heart needs to be filled and the correct vein length estimated. All SVG grafts tend to shrink a bit after grafting and hence 1-2cms extra length should be left to avoid premature graft failure. The SVG opening should be atleast 20% more than aortic opening to have a good cobra head configuration. The vein has to be beveled at 30 degree.
The lie of the LAD or diagonal vein grafts should take a deep concave course to join the aorta in an oblique manner at the 7 o’clock position at the anastomotic site, the ramus and obtuse marginal grafts should have their heel at 6 o clock position, the RCA vein at the 2-3 o clock positons and the PDA / PLB grafts take a course lateral to the atrium and leaving the aorta at about 1 o clock position. All proximals should be placed on normal aortic areas avoiding calcific sites and should be the left anterolateral and right anterolateral aspect of ascending aorta. Always be wary of patients coming back for AVR in future and there should be room for that procedure. The edges of the aortotomy should be free of any debris. The inside out technique placates any loose atheroma in the aorta and seems to a good technique.
All SVG grafts have to be deaired and after completion should have a good lie, lenght and configuration. Any deviation from this attracts revision of the graft. One can use a single bigger clamp to construct multiple proximals at one go [single clamp technique] or clamp the aorta multiple times with a smaller clamp.
The piggy back SVG anastomosis needs a special mention. Look for the lie; proximal on proximal configuration.
Additional reading: Rob and Smiths Cardiac Surgery Techniques.
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