This video demonstrates the technique of coronary artery bypass grafting with bilateral internal mammary arteries using composite Y-graft technique. The right internal mammary artery (RIMA) is harvested first as a skeletonized free graft and then the left internal mammary artery (LIMA) is harvested as a skeletonized pedicled graft. Before going on bypass when the heart is full and not arrested the precise marking of the Y-graft anastomosis site is possible. This site is marked on the LIMA at the level of the left atrial appendage. The composite Y-graft is constructed by anastomosing the proximal end of the RIMA to the marked site of the LIMA (end-to-side anastomosis) using 8-0 continuous running Prolene suture. The flow in the composite graft is checked and measured to make sure that it is 2 - 3 times more than the LIMA flow (measured before) to be able to provide enough blood to 2 and more coronary arteries to be bypassed. The cardiopulmonery bypass is started and the heart is arrested. LIMA to Diagonal and LAD sequential graft and RIMA to OM and PDA sequential grafts were done for this particular patient. Composite Y-graft function and patency is checked 3 months after surgery by 64 slice contrast CT scan. LIMA stem flow is checked after surgery by Dupplex investigation. Good flow is noted with predominant diastolic component. Good function and patency of the composite Y-graft is also seen on the angiogram 5 years after surgery. This operation let us avoid vein grafts and perform arterial revascularisation providing good and stable long-term results which is very important especially for the younger patients.
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