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Off‐pump CABG with lower sternotomy in a patient with dialysis access graft crossing the sternum

A 67-year-old male with diabetes and end-stage renal disease on dialysis was admitted with unstable angina and was found on cardiac angiography to have significant ostial left main disease extending into the proximal left anterior descending (LAD) artery. His dialysis graft had been placed across the upper chest anterior to the manubrium. At the time of surgery, a limited lowermidline incision wasmade from just below the angle of Louis to the xiphoid. The dialysis catheter was dissected from the subcutaneous tissue to limit the tension during sternal retraction for the dissection of the left internal mammary artery (LIMA). A lowerhemisternotomywas thenperformed from thexiphoid to the level of the third rib. The third interspace on the left was entered and divided in order to achieve appropriate exposure and mobilization. A RulTract retractor (RulTract Inc., Cleveland, OH) was used to lift the left hemisternum and the LIMA was dissected (Figure 1). An on-pump LIMA-LAD anastomosis was performed using a 7-0 running prolene