title: Multivessel awake off-pump coronary bypass grafting using median approach: technical considerations.
abstract: OBJECTIVE
  : Several reports of awake off-pump coronary artery bypass grafting (AOCAB) under high thoracic epidural anesthesia (TEA) for single-vessel grafts have been published, but few have described its application in multiple bypass procedures. We report the procedures and safety of AOCAB for multivessel disease.
  
  
  METHODS
  : Fifty-five multivessel AOCAB (52 men, 3 women; aged 68 ± 9.5 years) were performed at our hospital between 2003 and 2010. A medium sternotomy was made after TEA was established. During coronary artery anastomosis, a stabilizer and an apical suction device were used, and a coronary artery active perfusion system was used to maintain flow distal to the anastomosis. Pneumothorax due to pleural opening, when occurred, was repaired using Neoveil sheet and drainage tube.
  
  
  RESULTS
  : There was no operative death and no cerebral ischemia, cardiac arrhythmia, and chronic obstructive pulmonary disease. Operating time was 177 ± 35 minutes. Left internal thoracic artery was used in 55 anastomoses, right internal thoracic artery in 7, gastroepiploic artery in 17, radial artery in 48, and saphenous vein in 24. Time of anastomosis was 4.93 ± 0.92 minutes for left anterior descending coronary artery, 4.75 ± 1.21 minutes for circumflex artery, and 4.98 ± 1.02 minutes for right coronary artery. Intraprocedural pneumothorax occurred in 17 cases; 14 were repaired and nonintubated AOCAB was accomplished, 1 was intubated, and 2 had temporary assisted ventilation and laryngeal mask. Time to discharge was 15.5 ± 8.4 days.
  
  
  CONCLUSIONS
  : Multivessel AOCAB under TEA is not only feasible but also safe. Multiple grafts can be harvested under TEA, and complete vascularization is possible under constant monitoring of blood pressure and consciousness.
authors.affiliation: From the Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
authors.forename: Go
authors.initials: G
authors.lastname: Watanabe
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Ohtake
authors.forename: Shigeyuki
authors.initials: S
authors.lastname: Tomita
authors.forename: Shojiro
authors.initials: S
authors.lastname: Yamaguchi
authors.forename: Noriyoshi
authors.initials: N
authors.lastname: Yashiki
authors.forename: Hiroki
authors.initials: H
authors.lastname: Kato