Extrathoracic MIDCAB

The distal RCA and posterior descending artery are approached via a 2.5-inch subxiphoid incision. The xiphisternum is excised, and bilateral release of the costal diaphragmatic attachments helps provide better exposure of the target vessels. The right gastroepiploic artery is a frequently used conduit for this procedure.

The greatest technical limitation for MIDCAB techniques is multivessel disease. To bypass multiple coronary arteries using multiple arterial conduits, the transabdominal approach is performed through a 3-inch chevron epigastric incision. Division of bilateral recti with release of bilateral diaphragmatic attachments widely opens the substernal window. Bilateral mammary arteries and the right gastroepiploic artery are available conduits with this incision. The LAD is approached above the diaphragm, while the distal RCA, posterior descending artery, and posterial lateral marginal artery are approached through the diaphragm after mobilizing the left lobe of the liver.

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