In cases were a significant artery is totally occluded, theres a possibility to remove the atheroma, and using the same hole in the artery to perform an anastomosis ·this technique is called endarterectomy and is usually performed at the Right Coronary System.Reoperations of CABG (another CABG operation after a previous one), poses some difficulties: Heart may be too close to the sternum and thus at risk when cutting the sternum again, so an oscillating saw is used. Heart may be covered with strong adhesions to adjusting structures, adding to the difficulty of the procedure. Also, aging grafts pose a dilemma, whether they should be replaced with new ones or not. Manipulation of vein grafts risks dislodgement of atheromatic debris and is avoided. "Minimally Invasive revascularization" (commonly MIDCAB form minimally invasive direct coronary artery bypass) is a technique that strives to avoid a large sternotomy. It utilizes off pump techniques to place a graft, usually LIMA at LAD. LIMA is monilized through a left thoracotomy, or even endoscopically through a thoracoscope placed in the left chest. Robotic Coronary revascularization avoids the sternotomy to prevent infections and bleeding. Both conduit harvesting and the anastomosis are performed with the aid of a robot, through a thoracotomy. There is still no widespread use of the technique though. Usually it is combined with Hybrid Coronary Revascularization, which is the strategy where combined methods of CABG and PCI are employed.
Beck CS, used a carotid conduit to connect descending aorta to coronary sinus -the biggest vein of the heart, while Arthur Vineberg used skeletonized LIMA, placing it in a small tunnel he created next to LAD (known "Vineberg Procedure"), with the hope of spontaneous collateral circulation would form, and it did in canine experiments but was not successful in humans. Goetz RH was the first to perform an anastomosis of the IMA to LAD in the 1960 utilizing a sutureless technique.The development of coronary angiography in 1962 by Mason Sones, helped medical doctors to identify both patients that are in need of operation, but also which native heart vessels should be bypassed. In 1964, Soviet cardiac surgeon, Vasilii Kolesov, performed the first successful internal mammary artery–coronary artery anastomosis, followed by Michael DeBakey in the USA. But it was René Favaloro that standarized the procedure. Their advances made CABG as the standard of care of CAD patients. The CABG era
The "modern" era of the CABG begun in 1964 when the Soviet cardiac surgeon Vasilii Kolesov performed the first successful internal mammary artery–coronary artery anastomosis in 1964, while Michael DeBakey used a saphenous vein to create an aorta-coronary artery bypass. The Argentinean surgeon Rene Favaloro advanced and standardized the CABG technique using the patients saphenous vein.Introduction of cardioplegia led to CABG becoming a much less risky operation. A major obstacle of CABG during those times were ischemia and infarction, occurring while the heart was stopped to allow surgeons to construct the distal anastomosis.