Discover the steps of Coronary Artery Bypass Grafting – Step 1

Step 1: Opening and Heart Exposure in Coronary Bypass Surgery

Introduction

Coronary artery bypass grafting (CABG), also known as coronary bypass surgery, is a procedure that creates a grafted bridge between the aorta or one of its branches and the coronary arteries. The primary aim of this surgery is to restore proper blood flow to narrowed or blocked coronary arteries, often responsible for severe angina and myocardial infarction. ¹

This article focuses on the initial phase of the operation, namely the opening and exposure of the heart, and highlights the importance of medical devices used and their impact on the surgery’s success.

I. The Quality of Surgical Material

The quality of medical devices used is paramount. It directly impacts the success of the surgery, ensuring not only the effectiveness of each step but also the patient’s safety. Every tool, from hemostatic clips to pericardial sutures, must be carefully selected according to its technical properties and anatomical suitability.

A well-chosen set of materials can limit postoperative complications, such as hemorrhage or infection, and support an optimal surgical process.

II. Steps of the Procedure

1. Median Sternotomy

The chest is opened through a median sternotomy, an incision along the midline of the sternum. This approach is the most common for coronary bypass procedures, offering optimal access to the heart. An oscillating saw is used to divide the sternum, and this step must be performed carefully to minimize the risk of infection or postoperative complications.

2. Hemostasis

Managing hemostasis at this stage is crucial. Precise control of bleeding from mediastinal vessels with vascular ligation clips ensures maximum visibility for the surgeon and reduces hemorrhage risk.

Titanium hemostatic clips, such as the Clip 9 Vitalitec® or Clip SLS Vitalitec®, are often preferred here due to their high performance. Made of 100% titanium, these clips are biologically motionless, avoiding any backlash with surrounding tissues. Additionally, their X-ray opacity allows easy visualization in postoperative controls. Their double internal striation design provides excellent stability under blood pressure, adding optimal security when used on vessels.

3. Opening the Pericardium

After the sternotomy, the surgeon proceeds with the opening of the pericardium, a membrane that encases and protects the heart. The pericardium is incised using either an electric scalpel or scissors, and any thymus residue is removed for better exposure. This step allows the surgeon to clear cardiac structures for the upcoming surgery.

Medium-sized vascular clips (Clip Medium blue, 5.6 mm) are used to ligate small arteries, such as the pericardial and phrenic arteries, and veins around the thymus. These clips are chosen based on the surgeon’s preference and technique, ensuring precise hemostasis on these small vessels.

4. Pericardial Sutures for Heart Exposure

A crucial step in cardiac exposure involves fixing the pericardial edges with sutures to optimize heart access. These sutures retract cardiac structures laterally and upward, providing the surgeon with enhanced visibility.

Sutures are made using Polytresse® braided suture (polyester coated braids), non-absorbable suture, which offers optimum strength to withstand the high tension applied to the pericardium. It is essential that these sutures remain intact throughout the operation, as they play a vital role from the heart’s opening to the final closure.

III. Importance of Suturing

Suturing is not only integral to this initial CABG stage; it is required throughout the operation, from the creation of anastomoses to the establishment of cannulation and even during chest closure.

Conclusion

Opening and exposing the heart mark a crucial first step in the CABG procedure, laying the groundwork for the subsequent stages of surgery. This step demands high technical precision and careful selection of medical devices. Titanium hemostatic clips and braided sutures are essential elements ensuring the operation’s safety and success. The quality of these devices, particularly those provided by Peters Surgical, helps minimize risks and optimize operating conditions for the surgeon.

VITALITEC SLS-CLIP® TITANIUM HEMOSTATIC CLIP

INDICATIONS:

Mechanical occlusion of blood vessels. For use with VITALITEC clip appliers only.

Class III Medical Device- CE 0459 – Manufacturer: Peters Surgical.

Read instructions carefully before use.

VITALITEC® CLIP 9 TITANIUM HEMOSTATIC CLIP

INDICATIONS:

Mechanical occlusion of blood vessels. For use with VITALITEC clip appliers only.

Class III Medical Device- CE 0459 – Manufacturer: Peters Surgical.

Read instructions carefully before use.

POLYTRESSE®

INDICATIONS:

POLYTRESSE non-absorbable sutures are intended for general use in tissue approximation, ligation and/or prosthesis fixation in cardiovascular, ophthalmic, orthopaedic, digestive and parietal, gynaecological and urological surgery.

Class III Medical Device- CE 0459 – Manufacturer: Peters Surgical.

Read instructions carefully before use.

SOURCES :

¹ Groupe de travail : A. Courtin ; F. Dejean ; E. Dominici ; C. Draperi ; M. Houllé-Veyssière ; M. Lamraouah ; S. Méjean ; V. Rubio ; M. Wojtczak. Mai 2011. Publication « Le Pontage Coranien » du service Réanimation ADV-DAR « D » du CHU de Montpellier.