During a minimally invasive AVR case, a single SVG to the RCA can be performed. The PDA is more difficult to bypass, and unless the anatomy is very favorable, it will not be accessible. Before considering a bypass to the RCA, I prefer to stent the RCA, unless it is totally occluded.
1. It is best to perform the distal vein anastomosis before the AVR.
2. The best retraction method is placing multiple silk sutures on either side of the RCA as well as one retracting the artery cephalad. I have used different suction devices but the space is very limited. Occasionally a sponge stick can help.
3. The anastomosis needs to start at the toe of the vein. If one begins at the heel, which is the usual way, the toe will be very difficult to see.
I have enclosed representative pictures. Don’t let the pictures fool you. It does take a little practice!