[HSF] Full metal jacket

[Tohru Asai]

Zhandong
Good point! I am aware that it is Achilles heel. Therefore when I plan
sequential anastomoses, I consider followings carefully.
1. arterial conduits: good conduit luminal size, degrees of native stenoses,
avoid of kinking and/or torsion.
2. venous conduits: choice of the best segment, less venous valves, avoid of
valve close to anastomosis.

I am also aware that late development of atherosclerotic stenosis can occur
in vein. Usually when I use vein, mostly in urgent cases, one or two IMA are
used. So I hope in late period, the patient may need some area to be
revascularized, but not all myocardial area would be in danger like around
the world vein.

As far as arterial conduits, moderate stenosis causing flow competetion is
the unpredictable factor in long term. Therefore I carefully avoid these
vessels, especially when arterial conduit size is not large. On the other
hand, when target sites are mostly occluded in sick heart, I am not
concerned any thing.

And with these strategy and techniques, I think combination of off-pump and
skeletonized arteries works very well. Because it is very natural to design
graft arangements, to measure length, and to check graft flow following each
anastomoses. I believe it is the basic for advanced coronary
revascularization. I attach some angiograms of in-situ arterial OPCAB x6.
-- 
Tohru Asai


> One of the concern in multiple sequential grafts is the risk of losing
> multiple distals if the sequential graft goes down. It seems that you
> rooutinely doing them and not worried about it.