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Indications

• Coronary artery revascularisation using arterial conduit

Key points:

• Careful dissection
• Avoid injury to the phrenic nerve as you dissect near the apex 

Procedure

1. Chest should be opened as per "median sternotomy" technique
2. Tilt the patient away to expose the mammary bed
3. Open the pleura ~2cm from the edge to expose the posterior surface of the sternum (from start of rectus abdominis up until it splits)
4. Using a swab, clean the posterior surface of the sternum and identify the internal thoracic artery
5. Open up the pleura medial to the internal thoracic vessels
6. (start in the midline)
7. Dissect out the branches of the internal thoracic artery; double ligate with liga-clips and divide between the two
8. Once dissected out whole, clip the end with liga-clips and protect in a warm swab soaked in papaverine