Flexible side-biting aortic clamp via a centimetric proximal intercostal incision to facilitate proximal anastomosis during minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) via an anterolateral mini-thoracotomy represents a viable and safe approach. However, the proximal anastomosis of the saphenous vein to the ascending aorta can be technically challenging, particularly in cases with a prominent right ventricular outflow tract or pulmonary artery. In this report, we present an enhanced proximal anastomosis technique for minimally invasive coronary artery bypass grafting performed via intercostal thoracotomy. 45 patients with a mean age of 64.6 ± 9.0 years underwent minimally invasive coronary artery bypass grafting with enhanced technique via intercostal thoracotomy between July 2021 and November 2023. Multilevel pericardial retractions were employed to laterally displace the heart and a flexible side-biting clamp was placed on the ascending aorta via a 1-cm incision in the left second intercostal space, enabling handsewn proximal anastomoses on the ascending aorta. The mean number of grafts was 2.8 ± 0.5, with a total of 11 patients (24%) had 2 grafts, 32 patients (71%) had 3 grafts, and 2 patients (4%) had 4 grafts. Median operative time was 4.2 ± 0.7 h, mean intensive care unit stay was 1.5 ± 0.5 days, and mean in-hospital stay time was 9.1 ± 6.0 days. No in-hospital mortality occurred. This technique provides a reliable approach for overcoming technical limitations of proximal anastomosis in MICS CABG, especially when aortic access is problematic.