This is a very nice approach for a single bypass to the OM. It is optimal if there is an old SVG placed to the vessel that needs to by grafted. The patient is placed in an almost lateral thoracotomy position with the left groin exposed. I usually place a line in the left femoral vein in the event that I need to insert a venous cannula. Arterial access can be obtained directly in the descending aorta if need be. The incision is made in the lateral aspect of the chest and usually at the level of the lower aspect of the scapula. I use a soft tissue retractor as well. The descending aorta is exposed after the inferior pulmonary ligament is completely dissected free. The pericardium is opened below the phrenic nerve and retracted. The old SVG is followed until visualizing the OM. Of note, access to a high OM is not optimal via this approach. An off pump suction stabilizer is utilized to isolate the coronary. After this anastomosis is performed, a Satinsky clamp is placed on the descending aorta for the proximal anastomosis. The segment of vein is usually small and you need to let it loop down a little so that when the lung inflates, it does not place excessive tension on the graft. I also place a marker around the proximal in the event that the patient needs to be cathed, it can be easily identified. Usual LOS is 3 days in hospital.
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