Recently, an operation first described in 1952 by Demikhov 1 and further developed by Kolesov and Potashov 2 has reemerged as a minimally invasive procedure in which the left internal thoracic artery (LITA) is anastomosed to the left anterior descending coronary artery (LAD) in a beating heart. An anterior mediastinotomy is used to gain access to both arteries. We, like others, 3 have used the descending thoracic aorta and the left subclavian artery as inflow conduits to perform coronary bypass procedures without extracorporeal circulation. Recently, however, we encountered a case in which these sources of inflow could not be used. We had to resort to the axillary artery to perform the proximal anastomosis. To tunnel the graft into the chest cavity, we resected the anterior portion of the first rib and performed the rest of the operation through an anterior mediastinotomy.A 63-year-old man was admitted with congestive heart failure, severe pulmonary edema, and liver and renal dysfunction. The patient had undergone three previous coronary bypass operations. The most recent one, in 1995, was performed on an urgent basis after failure of a stent to reopen the anastomotic site between the LITA and the LAD. According to the surgeon's operative note at the specialized stent center, the patient had a complicated operation that required delayed sternal closure and a
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