[[300 Technical Outline of Coronary Artery Bypass Grafting]] # Proximal Free Arterial Anastomosis - There are different theories for the drop in ten year patency from *in situ* arterial grafts to free grafts. Obviously, in one case the anastomosis has been created by God, and in the other the hand of man. One theory ascribes the drop to the disparity of wall thickness between that of the aorta and that of the arterial graft. There is probably more to this theory when the diameter of the arterial conduit is small. I have had very successful large mammary and radial grafts directly taken off the aorta. Give serious consideration to the use of a single fire of 2.5 mm aortotomy hole punch in this case. - Other options for the proximal include - The hood of a vein graft - A more distal aspect of the vein graft, particularly useful if the arterial conduit is short - Just remember that the further from the hood, the more the following equation is true: artery plus vein = vein - A patch of native or fixed bovine pericardium sewn to the aorta[^a] - Another arterial graft, if sufficiently large[^b] - Except in Off Pump situations, the free arterial proximal should not be created until the option for proximal is already in place, and after the free arterial distal - In all options, and particularly in the case of the proximal off the aorta, the anastomosis should be performed as a parachute - Bites of the arterial conduit should be as delicate as possible, with only a little extra depth for strength at the wings. [^a]: This is a handy technique for vein grafts when an unexpected caseating atheroma is encountered, and can also be useful when an autoimmune aortitis is suspected. [^b]: A very useful source of vein and arterial grafts in porcelain aorta situations