CTSNet Step-by-Step Series: Proximal Anastomosis

Sir, Whilst I agree with the basic tennet of the authors' comments on top-end anastomoses, I would like to make one important comment. The most important part of any conduit is the endothelium, and as such, it needs to be disturbed as little as possible. Were a trainee of mine to grasp the endothelium of the vein as demonstrated in the video presented, I would be particularly unhappy, and were they to persist, I would take over the procedure to prevent further potential injury. Exposure for anastomosis is perfectly possible by grasping the adventitia alone, if perhaps a little more fiddly. A second minor point is that the principles are identical for OPCABG cases, with the benefit of the heart being appropriately filled, so that conduit length and lie concerns are more straightforward without any element of guesswork. Andrew Muir Cardiac surgeon

I don't see the problem with the operating physician's technique. Grasping the very edge of the graft and the endothelium is not an issue, as that portion of the endothelium will not come into contact with the blood flow - it is the part that will be apposed to the aortic adventitia under the sutures. So in other words, doctor Muir please let your trainees finish their anastomoses and just silently cringe at the thought of the endothelium, as that part of it doesn't need to be untouched.

I TOOAGREE AND GRASPING WITH AN ATRAUMATIC RING PICK UP SHOULD LEAVE NO WORRIES.