The 10 Commandments for Proximal Anastomosis During CABG: Techniques and Technologies for Vein and Arterial Grafts

In coronary artery bypass grafting (CABG), the proximal anastomosis and management of the ascending aorta are critical moments that significantly influence the risk of perioperative stroke, due to the potential for cerebral embolization from dislodged aortic debris or hypoperfusion caused by hypotension.^1,2 Perioperative stroke remains one of the most severe complications of CABG, leading to significant morbidity, mortality, and economic burden.^3,4

Regardless of the graft type used, unless it is grafted in situ, a proximal anastomosis on the ascending aorta or on a great vessel is required. Traditional methods involve partial clamping of the aorta for a hand-sewn anastomosis, whether for on-pump or off-pump CABG. With this common technique, patients with ascending aortic disease or calcification are at heightened risk of mechanical damage to the aortic intima, ranging from disruption of aortic atheroma to aortic dissection or even rupture, due to the lateral cutting force exerted by the side clamp.⁵

Despite the proximal anastomosis being previously underappreciated, recent advancements in surgical tools and techniques have led to a renewed recognition of its importance. These innovations provide promising opportunities to improve procedural accuracy and patient outcomes. Irrespective of the chosen revascularization technique, it is essential for the surgeon to acknowledge and abide by certain principles to ensure a safe procedure without long-lasting neurologic complications. These guiding principles are shown here as the 10 commandments for proximal anastomosis during CABG.