Four-Stitch Side-to-Side Anastomosis for Sequential Coronary Artery Bypass Grafting Tadashi Tashiro, MD, PhD, Hideichi Wada, MD, PhD, Noritoshi Minematsu,

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Four-Stitch Side-to-Side Anastomosis for Sequential Coronary Artery Bypass Grafting Tadashi Tashiro, MD, PhD, Hideichi Wada, MD, PhD, Noritoshi Minematsu, MD, Yuta Sukehiro, MD, Shinji Kamiya, MD, Masahiro Osumi, MD, Noritsugu Morishige, MD, PhD The Annals of Thoracic Surgery Volume 99, Issue 3, Pages 1092-1094 (March 2015) DOI: 10.1016/j.athoracsur.2014.10.074 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Sequential steps in the four-stitch side-to-side anastomosis (4-SSSA) technique. (A) A small lengthwise incision is made in the in the radial artery (RA) and saphenous vein grafts (G) across which double-armed polypropylene sutures are placed (1, 2). (B) Next, the target coronary artery (CA) for anastomosis is opened lengthwise and 2 needles are placed across it using double-armed polypropylene sutures (3, 4). (C) One side of the double armed needles (2) is placed on the graft to the proximal side of the target CA from inside to outside and ligated. (D) Next, another side of the double armed needles in the CA is inserted from inside to outside in the graft (3, 4). Another side of the double-armed needles placed on the graft is inserted from inside to outside on the target CA distal side (1). (E) Ligation is carried out and hemostasis confirmed. The Annals of Thoracic Surgery 2015 99, 1092-1094DOI: (10.1016/j.athoracsur.2014.10.074) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig. 2 Angiogram performed 2 weeks after coronary artery bypass graft surgery. The radial artery (RA) graft was anastomosed to the first, second, and third obtuse marginal branches; the saphenous vein graft (SVG) was anastomosed to the right posterior descending artery and right posterolateral artery. All four-stitch side-to-side anastomosis were patent despite poor coronary artery runoff. (A) RA-OM-OM-OM; (B) SVG-RPL-RPD. (OM = obtuse marginal; RPD = right posterior descending; RPL = right posterolateral.) The Annals of Thoracic Surgery 2015 99, 1092-1094DOI: (10.1016/j.athoracsur.2014.10.074) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions