Imma Case Study
IMA retractor was used to elevate the sternum to expose the IMA after median sternotomy. Papaverine will be injected into the IMA lumen to prevent vasospasm. Heparin will also be administrated before clamping the IMA with a small bulldog clamp to prevent thrombosis. The IMA can also harvested endoscopically through thoracic ports at the fourth intercostal space. The saphenous vein can be harvested from one or both legs, either endoscopically or openly. The vein will be divided into separate shorter segments according to the number of necessary bypasses, and each segment will be used for bypasses individually. The distal end of the vein will be anastomosed proximately with the aorta in a reversed position so that the semilunar valves
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do not interfere with blood flow. After the graft harvesting, the length, the leaking, the quality of the graft will be evaluated and the surgeon will decided how much needed for the surgery in order to prevent thrombosis and kinking.
Surgical Procedure After sternotomy, the surgeon divided the sternum from the sternal notch to the xiphoid process.
A sternal retractor was used and IMA was harvested and clamped with bulldog. The pericardium was continued to incise and pericardial edges was retracted with sutures to enhance exposure of the heart. The surgeon then identified the affected coronary artery, and coronary anastomotic site stabilizer was then used to reduce the movement of the beating heart and isolate the target coronary artery site for anastomosis (Fig.3). A fine mist of humidified CO2 gas was sprayed over the anastomotic site to clear the bleeding. Vessel loops, or silastic shunts was used to control bleeding. The distal anastomosis of the IMA with coronary artery was then performed side to side anastomoses with fine cardiovascular suture. Since IMA remained attached to the subclavian artery, no proximal aortic anastomosis required (Behny, 2006); the blood flow is restored as soon as the IMA anastomosis is established. If saphenous vein free graft was used during the off pump CABG, the distal end of the vein graft will be performed anastomosis first with the coronary artery, and then the other end of the vein graft will be sewn to the aorta either with the sutureless anastomosis device (Calafiore, et al., 2001) or hand sutured to aorta with the help of Hegar dilator loaded with the saphenous vein (Dikmengil, Ozeren, Aytacoglu, & Sucu, 2005) to minimize manipulation of the aorta . A drain will be
left and removed after 24 hours. The sternum will be closed with the steel wire cerclage or with plates and screws followed by fascia approximation and skin closure.
do not interfere with blood flow. After the graft harvesting, the length, the leaking, the quality of the graft will be evaluated and the surgeon will decided how much needed for the surgery in order to prevent thrombosis and kinking.
Surgical Procedure After sternotomy, the surgeon divided the sternum from the sternal notch to the xiphoid process.
A sternal retractor was used and IMA was harvested and clamped with bulldog. The pericardium was continued to incise and pericardial edges was retracted with sutures to enhance exposure of the heart. The surgeon then identified the affected coronary artery, and coronary anastomotic site stabilizer was then used to reduce the movement of the beating heart and isolate the target coronary artery site for anastomosis (Fig.3). A fine mist of humidified CO2 gas was sprayed over the anastomotic site to clear the bleeding. Vessel loops, or silastic shunts was used to control bleeding. The distal anastomosis of the IMA with coronary artery was then performed side to side anastomoses with fine cardiovascular suture. Since IMA remained attached to the subclavian artery, no proximal aortic anastomosis required (Behny, 2006); the blood flow is restored as soon as the IMA anastomosis is established. If saphenous vein free graft was used during the off pump CABG, the distal end of the vein graft will be performed anastomosis first with the coronary artery, and then the other end of the vein graft will be sewn to the aorta either with the sutureless anastomosis device (Calafiore, et al., 2001) or hand sutured to aorta with the help of Hegar dilator loaded with the saphenous vein (Dikmengil, Ozeren, Aytacoglu, & Sucu, 2005) to minimize manipulation of the aorta . A drain will be
left and removed after 24 hours. The sternum will be closed with the steel wire cerclage or with plates and screws followed by fascia approximation and skin closure.