'Thinking outside the sternum' in redo CABG: radial artery from descending aorta to obtuse marginal branch.

Redo coronary artery bypass grafting (CABG) is arguably one of the most technically demanding procedures in cardiac surgery due to the presence of dense mediastinal/pericardial adhesions making target vessel identification challenging, limited conduit availability and the risk of injury to the heart and patent grafts. Resternotomy, in particular with the right ventricle and/or previous grafts adjacent/adherent to the posterior sternal table, could result in catastrophic complications. In selected patients, alternative strategies can be used to reduce these hazards and increase procedural safety. This video tutorial presents the surgical technique performed in a 77-year-old gentleman with a prior history of CABG, who underwent successful off-pump revascularization of the obtuse marginal branch with a radial artery graft anastomosed to the descending thoracic aorta through a left thoracotomy approach. The step-by-step video demonstrates conduit harvesting, patient positioning, descending aorta exposure and key technical nuances associated with both, proximal and distal anastomoses. This approach exemplifies how 'thinking outside the sternum' can transform a high-risk redo operation into a safe, reproducible procedure, thereby eliminating the above-mentioned risks associated with a resternotomy. The tutorial aims to provide practical guidance for experienced coronary teams seeking to expand their surgical armamentarium and improve outcomes of complex redo CABG procedures.