Anterior approach to the upper dorsal spine (T1 to T4) using single-stage sterno-biclavicular mobilization

The approach of thoracocervical spine junction is sometimes difficult. The authors expose a technique to realize the exposition of the lower cervical spine and upper thoracic vertebrae (T1 to T4). An anatomical reconstruction is performed. Advantages and inconveniences of this approach are exposed before underline its indications.     

Oblique transcorporeal approach to anteriorly located lesions in the cervical spinal canal

Summary The technique of obliquely drilling out the postero-lateral part of the cervical vertebral bodies is described. It uses the antero-lateral (retro carotico-jugular) approach to control and displace the vertebral artery postero-laterally and to expose the lateral aspect of the vertebral bodies. It provides, through a wide field and with minimal retraction of the carotid artery and the internal jugular vein, an extensive view of the anterior aspect of the spinal cord. It has already been used to treat 15 anterior lesions compressing the spinal cord including neurinomas and osteophytes.     

A perspective for the selection of surgical approaches in patients with upper thoracic and cervicothoracic junction instabilities

OBJECTIVE: To reach the upper thoracic vertebrae, a number of extensive approaches have been proposed. The purpose of this study is to provide a clear perspective for the selection of surgical approaches in patients who undergo vertebral body resection, reconstruction, and stabilization for upper thoracic and cervicothoracic junction instabilities. METHODS: Seventeen patients with upper thoracic or cervicothoracic junction (C7-T6) instability underwent surgery between January 1999 and May 2004. All patients presented with pain and/or neurological deficits. The causes of instabilities were 10 traumas and 7 pathological fractures. The approach chosen was primarily dictated by 3 factors including (1) type of injury, (2) level of lesion, and (3) time of admission. Ventral surgical approach was performed to all pathological and traumatic fractures causing anterior spinal cord compression. Level of lesion determined the selection of the type of ventral surgical approach, namely, supramanubrial, transmanubrial, or lateral transthoracic. On the other hand, combined (anterior and posterior) approach was performed to all late admitted trauma patients. RESULTS: Twelve anterior, 2 combined (anterior and posterior), and 3 posterior approaches were performed in this study. Anterior approaches included 3 transmanubrial, 5 upper lateral transthoracic, and 4 supramanubrial cervical dissection procedures for decompression, fusion, and plate-screw fixation depending on the levels of the lesion. The mean follow-up period was 18 months, ranging from 10 to 58 months. Nonunion or instrument-related complications were not observed. The postoperative neurological conditions were statistically significantly better than the preoperative ones (P = .003). CONCLUSION: Consideration of the type of injury, level of lesion, and time of admission can provide a perspective for the selection of side of surgical approach for this transitional part of the spinal column. This study also suggests that supramanubrial cervical approach achieves sufficient exposure up to T2, transmanubrial approach for T3, and lateral transthoracic approach below T3.     

Sternum-splitting approach for ossification of the posterior longitudinal ligament in the cervico-thoracic junction

In this paper the author reported an operative approach for ossification of the posterior longitudinal ligament (OPLL) of the lower cervical and upper thoracic vertebrae. There are two types of surgery for OPLL, namely, posterior and anterior approaches. As a rule, we utilize an anterior approach for OPLL. Recently we performed a modified sternum-splitting approach in surgery for OPLL in the cervico-thoracic junction. In the original trans-sternal approach introduced by Cauchoix, the sternum is split from the suprasternal notch to the xiphoid process. We cut the manubrium only. However, a satisfactory exposure of the cervico-thoracic vertebrae down to the third thoracic level was obtained. After reaching the anterior surface of the cervico-thoracic vertebrae, the central portion of the vertebral body and the ossified lesion between the lower one third of the C7 vertebral body and the upper one third of the Th3 vertebral body were removed with an air-drill under an operating microscope. The longitudinal bone defect of the vertebral bodies was filled with a bone graft obtained from the iliac bone. Removal of the ossified lesion in the cervico-thoracic junction can be performed safely by utilizing the modified sternum-splitting approach. This approach can be applied also to endarterectomies at the origins of the vertebral arteries and the right subclavian artery.     

上胸椎前方手术入路的解剖及其临床意义

目的研究上胸椎与其毗邻组织结构的解剖关系,为探讨上胸椎前方手术入路提供参考.方法取20具经防腐处理的尸体标本,模拟上胸椎前路手术,部分劈开胸骨,并分别经不同的血管、神经间隙显露椎体,比较不同的血管、神经间隙入路的暴露范围及其优缺点.观察上胸椎毗邻的血管、神经等组织结构的走行及其与椎体的对应关系.结果头臂干外侧间隙入路（头臂干与右头臂静脉、左头臂静脉根部之间的间隙）95%可显露达T3椎体以下,而头臂干内侧间隙入路（气管食道鞘与头臂干、左头臂静脉之间的间隙）只有45%可显露达T3椎体以下.上腔静脉与升主动脉之间的间隙只能在直视下显露T4,并且视野狭小.右喉返神经在T1,2水平从迷走神经发出,绕过锁骨下动脉斜行走向内上,在T1椎体上缘水平附近走向气管食道沟.胸导管75%在T1椎体到T1-2椎间盘水平入左侧静脉角,约50%最高点达T1水平.左头臂静脉55%平T3椎体水平从上腔静脉发出.主动脉弓主干约80%在T3-4椎间盘水平横过椎体.结论头臂干外侧间隙入路操作简单、显露清楚,可以很容易地显露T3和T4椎体;头臂干外侧间隙与头臂干内侧间隙相比,可多显露0.5～1个椎体.但由于迷走神经穿过此间隙并在此发出心支,所以应注意保护迷走神经.在右侧施行T1,2水平手术时易损伤右喉返神经.在采用左侧入路时应注意胸导管的走行,避免损伤胸导管.     

上胸段脊柱病变的前路与后路手术治疗

目的观察比较前、后手术入路治疗上胸段脊柱病变的疗效。方法选择上胸段脊柱病变56例,其中肿瘤27例,结核23例,陈旧性外伤6例,分别经前、后路病灶切除减压、植骨,大部分(48例)辅以内固定。随访6～48个月。结果本组均安全度过围手术期,3例术后发生乳糜漏,4例出现喉返神经牵拉伤所致一过性声音嘶哑,4例出现一过性膈神经刺激引起的呃逆症状。48例术后神经功能有不同程度改善,8例无明显改善。随访期间1例于1个月后双侧肺炎死亡,2例局部肿瘤复发,2例局部结核复发,1例肿瘤细胞全身转移死亡。均无断钉及内固定脱落。结论对上胸段脊柱病变正确选择应用前、后入路手术可暴露病变部位,彻底清除病灶。     

Transthoracic approaches to the lesions of thoracic cord and thoracic vertebrae

Experiences of transthoracic approaches to the thoracic cord lesions were reported. Since 1983, we have performed six transthoracic approaches to the thoracic lesions; one thoracic OPLL, one dumbbell-shaped neurinoma, two thoracic soft disc, one epidural metastatic tumor to thoracic vertebrae. From the viewpoint of surgical anatomy, the thoracic vertebrae show a physiological kyphosis and the subarachnoid space of the ventral site is narrower than that of the dorsal site. Due to such anatomical characteristics, the thoracic laminectomy for decompression is not so effective as in the cervical or lumbar region and a relatively small mass lesion can bring a paraplegic state. The lesion of the ventral site of the thoracic cord has been regarded as no man's land because of poor results of posterior approaches. Instead of posterior approaches, anterior or anterolateral approaches with transthoracic route have been adopted. In the present paper, we used transthoracic anterolateral approaches for four patients and anterior sternum-splitting approach for two patients. The operative procedures of the approaches were described in detail. By these approaches, we could treat four patients with favourable results but the result of thoracic OPLL was poor. The cause of this poor result seemed to depend upon the intraoperative compression of the thoracic cord. For the troublesome complication, we described the postoperative cerebrospinal fluid leakage into thoracic cavity with respiratory disturbance. Several devices to prevent such troublesome complication were discussed.     

Aortic arch repairs through three different approaches.

OBJECTIVES: The outcome of aortic arch repairs by means of three different approaches between 1990 and January 2000 was reviewed. METHODS: In total 39 patients aged 71.5+/-6.2 years were operated on. The three different surgical approaches depended on the anatomical positions of the aneurysms and on their proximal or distal extension; a median approach was employed in 23 patients, whereas a left postero-lateral approach was used in eight patients. More recently, in eight cases a left antero-lateral approach was applied. All patients underwent open aortic anastomosis without any clamp on or around the aortic arch. During the procedure, the brain was protected by a combination of profound hypothermic circulatory arrest and several techniques of retrograde cerebral perfusion. RESULTS: Permanent cerebral dysfunction occurred in four patients: two in the median approach and two in the left postero-lateral approach. There were two hospital deaths (5.3%) and six late deaths, all of which belonged either to the median group or to the postero-lateral group. The antero-lateral approach did not produce any cerebral dysfunction, early death, or late death. CONCLUSIONS: The outcome of aortic arch repairs using profound hypothermic circulatory arrest and variable techniques of retrograde cerebral perfusion, by means of three different approaches, was satisfactory. Of the three approaches, the antero-lateral approach can be employed easily, whether aneurysms extend proximally or distally.     

Cervicomanubrial route for the ventral upper thoracic spine: technical note about six cases

Ventrolateral cervicotomy provides a narrowed working space for surgical management of upper thoracic spine. We report our experience about ventral upper thoracic spinal cord decompression with reconstruction and plating via the cervicomanubrial route. Six patients (24 to 75 years old) were operated on by the same operator (LN) by cervicomanubriotomy from 2002 to 2007 for upper thoracic spinal cord compression (one case of Pott's disease, three cases of metastases, one fracture, one invasive hemangio-epithelioma), with a good outcome in five patients. Lesions were located from the cervicothoracic junction down to the fourth thoracic vertebra (T4). In all cases, anterior spinal cord decompression, strut graft reconstruction (iliac bone in two cases, cement in four cases) and osteosynthesis were performed. In two cases, a second stage posterior decompression with fixation was performed. The approach begins by a left sided anterior cervicotomy, medial to the sternocleidomastoid muscle and lateral to the trachea and esophagus, associated with division of the infrahyoid muscles close to their insertion at the upper thoracic outlet followed by osteotomy of the manubrium sterni. Then, division of the thyropericardic fascia and thymus, control of the brachiocephalic vein, control of the thoracic lymphatic duct and the horizontal thoracic aorta are performed. The ventral part of fifth cervical vertebra body down to T4 is then exposed between the left primitive carotid artery laterally, the esophagus medially and the thoracic aorta caudally. Compared to total sternotomy without or with clavicle resection, cervicomanubriotomy seems to be a less aggressive, safe and reliable procedure.     

显微镜与内镜下不同纵裂入路的结构显露特点及其解剖结构标志定位

目的探讨显微镜与内镜下不同纵裂入路的结构显露特点及解剖结构标志定位。方法成人尸头10具,分为A组和B组,每组5具,分别采用经前额纵裂入路和经纵裂胼胝体脉络膜裂入路联合室内孔入路,在显微镜和内镜下观察内部结构。结果显微镜与内镜下经前额纵裂入路微创并可充分显露和定位鞍区和第三脑室,有利于切除第三脑室前部和鞍区肿瘤,而经纵裂胼胝体脉络膜裂入路联合室内孔入路微创并可充分显露和定位第三脑室及侧脑室解剖结构,有利于第三脑室、房部、体部及侧脑室额角的手术操作。结论两种纵裂入路均可在显微镜、内镜下充分显露第三脑室等部分结构,组织创伤小,临床上可根据病变特点和手术需求选择合理的入路方式。     

Transoral fusion for high cervical fractures

We report three patients having transoral fusion at C2/3 or C3/4 after fractures, with no infections or surgical complications and sound union. The operative technique and the relative merits of different approaches to the upper cervical spine are discussed and the transoral approach to the anterior aspect of the upper three cervical vertebrae is commended to the specialist surgeon.     

小牛与人颈椎解剖结构的比较

目的比较小牛与人颈椎节段的解剖结构,探讨小牛颈椎是否合适在脊柱体外研究中替代人的脊柱标本。方法对12具小牛颈椎标本和8具人体颈椎标本进行形态解剖学测量。测量C1-7的椎体宽度、椎体长度、椎体高度、椎管的宽度、椎管的深度、椎弓根宽度、椎弓根高度、椎弓根角度、椎体总宽度及椎体总深度。结果小牛颈椎从C3-7与人颈椎在解剖学上比较相似,但也有许多不同：①小牛颈椎比人大,人颈椎大约为小牛颈椎的75％;②小牛颈椎椎弓根比人粗,椎弓根角比人大;③小牛颈椎横突比人短;④小牛颈椎棘突短且多为水平位;⑤小牛颈椎齿突长宽明显比人大。结论本研究为小牛颈椎动物实验研究提供了解剖学参考数据;小牛颈椎解剖在某些方面与人具有相似性,还需进一步研究其与人颈椎间生物力学的差异。     

上胸椎前方手术入路的CT影像学研究

目的：上胸椎前方手术入路的相关研究鲜见文献报道,并且其研究结果之间存在着较大的差异。本研究利用CT影像定位分析的方法,研究上胸椎前方不同血管间隙所能暴露的椎体范围,为制定上胸椎前路手术的术前计划提供参考。方法：自2008年10月至12月,随机选取120例正常胸部CT片,男58例,女62例;年龄16-75岁,平均（40．3±12．3）岁。利用胸部CT片的X线定位图像,定位左头臂静脉上缘与正中矢状面交点、左右头臂静脉汇合点上缘、气管分又上缘所平对的椎体水平;在垂直视野下且不向尾侧牵拉重要解剖结构的情况下,上述各点分别代表前方入路间隙E1（气管食管鞘与两侧血管鞘之间的间隙）、E2（右头臂静脉、头臂干与左头臂静脉根部之间的间隙）、E3（升主动脉与上腔静脉之间的间隙）尾侧暴露的椎体水平。结果：在120例样本中,有105例T2椎体可通过E1显露（87．5％）,有82例T3椎体可通过E2显露（68.3％）,有89例T4椎体可通过E3显露（74．2％）。结论：3种上胸椎前方入路间隙所能暴露的椎体范围存在差异,术前可根据患者的胸部CT片选择恰当的入路间隙。     

Trans-cleido-manubrial approach to the upper thoracic spine (T1-T2)

Authors describe their own experience of Sundaresan anterior approach and exposure of the upper thoracic vertebrae (T1-T2) including resection of the internal third of the clavicle and manubrium sterni. They point out technical details of that surgical approach and its indications.     

Cervicothoracic junction fracture/subluxation after multilevel anterior cervical spine fusion surgery

Background context

Several authors have reported cervical dislocations and fracture-dislocations above, below or through the fused cervical segment after cervical fusion. No previous reports have described fracture/dislocations at the cervicothoracic junction (CTJ) after multilevel anterior cervical spine fusion.

Purpose

To report CTJ fracture/subluxation after multilevel anterior cervical spine fusion surgery, a technique for surgical management and strategies to prevent this avoidable complication.

Study design

A case report and review of the literature.

Methods

A 61-year-old women underwent anterior cervical decompression and fusion (ACDF) from C3 to C7. The patient did well postoperatively until she suffered a CTJ fracture/subluxation 4?months later sustained during a fall.

Results

The patient underwent posterior and anterior fusion surgery C7–T2. Radiographs 2?years after her reconstruction surgery showed solid fusion from C3 to T2.

Conclusions

The CTJ area is susceptible to injury because it represents the transition between mobile and relatively immobile portions of the spine, especially when a long lever arm is created by a low cervical fusion. It is difficult to image with plain radiographs, and therefore, injury may be easily overlooked. If overlooked, severe neurological injury can result. Anterior and posterior fusion is often necessary to appropriately stabilize the CTJ after fracture/dislocation.     

MRI测量对上胸椎肿瘤手术入路选择的意义

目的：探讨术前MRI测量对上胸椎肿瘤前路切除手术入路选择的意义。方法：对8例上胸椎肿瘤患者术前进行MRI检查，在MRI矢状位图片上经胸骨切迹作与胸骨柄纵轴相垂直的线P，经病变椎体尾侧紧邻正常椎体的上、下终板作两个终板的切线E1和E2，分别记录P与脊柱相交的椎体水平及E1、E2与胸骨相交的椎体水平。P经过病变椎体远侧正常椎体，E1和E2经过胸骨切迹或其上方者采用低位颈前切口；E2经过胸骨柄上部者采用部分胸骨和／或部分内侧锁骨切除入路。P经过病变椎体或E1和E2经过胸骨柄中下部者采用后外侧经胸腔人路完成手术。结果：7例患者P经过病变椎体远侧正常椎体，其中4例E2经过胸骨切迹或其上方者有3例通过低位颈前切口完成了肿瘤的前路切除，1例显露不佳，切除少量左侧锁骨内侧部分增加显露后完成手术；3例E2经过胸骨柄上部者采用部分胸骨和／或部分内侧锁骨切除人路完成手术。1例P经过病变椎体，E1和E2经过胸骨柄中下部者采用后外侧经胸腔人路完成手术。未出现与手术相关的血管和神经损伤等并发症，3个月随访时内置物无松动、移位和断裂。结论：术前MRI测量有助于选择适当的手术入路，并可帮助判断肿瘤切除后胸椎前路的融合固定方式。     

上位颈椎前路手术咽后入路“窗口”显露技术的临床应用观察

目的：探讨上颈椎前路减压经咽后入路＂窗口＂显露技术在上颈椎损伤手术中的应用。方法：2000年1月至2008年7月手术治疗上位颈椎损伤患者5例,男4例,女1例;年龄16～68岁,平均35岁。C2椎弓骨折（HangmanⅡ型）2例,C2,3椎间盘突出症2例,C2椎体结核1例。所有患者经高位前方咽后入路舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂成功获得显露。Hangman骨折复位后行C2,3椎间盘切除椎间植骨融合内固定。C2,3椎间盘突出症患者行相应椎间盘切除,减压植骨融合内固定。C2椎体结核行病灶清除并植骨等。结果：5例患者均成功在舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂显露出C1前弓-C3椎体。随访5～26个月,平均13.5个月。无伤口感染,无颈部重要血管神经损伤。患者的神经症状恢复良好,所有患者植骨都获得了融合。结论：前方咽后入路的＂窗口＂显露技巧可使上颈椎获得理想的显露,创伤小,切口并发症少,有相关经验后也比较安全。     

To cross or not to cross the cervicothoracic junction in multilevel posterior cervical fusion: a systematic review and meta-analysis

BACKGROUNDInclusion of the cervicothoracic junction (CTJ) during decision-making regarding the surgical level of multilevel posterior cervical fusion (PCF) surgery remains the subject of debate, largely due to a lack of studies on the topic. Thus, we considered that meta-analysis based on recent high-quality clinical studies might enable better-informed decision-making regarding the selection of the distal level of multilevel PCF, particularly concerning the advisability of crossing the CTJ.PURPOSETo compare the outcomes of patients who underwent multilevel PCF with or without crossing the CTJ (the thoracic and cervical groups, respectively) by the distal construct.STUDY DESIGNA systematic review and meta-analysis.METHODSWe searched the Cochrane, Embase, and Medline databases for articles that compared the intra- and post-operative outcomes of patients who underwent multilevel PCF surgery with or without extension of surgery to include the CTJ, using January 7, 2021, as the publication cutoff date. Group differences in primary and secondary outcome measures were analyzed for significance (p<.05). All reported means were pooled.RESULTSA total of 1,904 publications were assessed, and eight studies met the study criteria. The cervical group had a significantly greater fusion rate than the thoracic group (p=.03), but higher adjacent segment disease (ASD) and reoperation rates (ASD: OR=3.15, p=.007; reoperation: OR=1.93, p=.008). As regards surgical outcomes, mean blood loss was less and operation time was shorter in the cervical group (p=.008 and .009, respectively). However, mean hospital stays were not significantly different (p=.12), and neither were the rates of complications, such as metal failure and hematoma.CONCLUSIONSIn the current study, fusion rate, blood loss, and operation time were better in the cervical group than in the thoracic group, but ASD incidence and ASD-related complication rates at the CTJ were greater in the cervical group. For patients with higher risk factors for adjacent-segment degeneration, crossing the CTJ may be warranted.     

Anatomical variations of rami communicantes in the upper thoracic sympathetic trunk.

OBJECTIVE: The aim of this study was to clearly delineate the anatomical variations of the communicating rami in the upper thoracic sympathetic nervous system and to help develop better surgical method for essential palmar hyperhidrosis. METHODS: Anatomical dissections of the upper thoracic sympathetic chains with sympathetic ganglia and communicating rami have been carried out in 42 adult Korean cadavers (male 26, female 16). The rami communicantes were classified into three types (Normal: transverse or oblique rami connected to the intercostal nerve of the same level; AR: ascending rami connected to the higher level; DR: descending rami to the lower level) based on the anatomical relationship of the thoracic sympathetic ganglia to the intercostal nerves. Both sides of the upper thoracic sympathetic nervous system were compared in the same individual. The number of the communicating rami was recorded in 32 cadavers (64 sides). The distance from the rami communicantes to the sympathetic trunk was measured in 26 cadavers (52 sides). RESULTS: The incidence of AR (ascending rami) and DR (descending rami) arising from the second sympathetic ganglion was 53.6% (45/84), 46.4% (39/84). From the third thoracic sympathetic ganglion, the incidence of AR was 5.9% (5/84) and that of DR was 26.2% (22/84). And in the fourth thoracic sympathetic ganglion, the incidence of AR was 4.8% (4/84) and DR was 8.3% (7/84), respectively. When we compared anatomical structures of both sides among the 42 cadavers dissected, only 14.3% (6/42) had similar anatomy of the rami communicantes bilaterally. Among 32 cadavers (64 sides), the mean number of rami communicantes at the second thoracic sympathetic ganglion was 2.1/2.5 in the left and the right side. At the third and the fourth thoracic sympathetic ganglion, the mean number was 1.9/1.6 and 1.7/1.7 in each side. The mean distance from the thoracic sympathetic chain to the most distal communicating rami of the left and right side at the second intercostal nerve was 7.81/9.40 mm among 26 cadavers. The mean distance of each side was 6.81/7.94 mm at the level of the third intercostal nerve. And at the level of the fourth intercostal nerve, the mean distance was 7.48/10.92 mm, respectively. CONCLUSION: On the basis of this study, the anatomical variations of communicating rami could explain some surgical failures and recurrences. Moreover, in addition to the conventional surgical methods (sympathectomy, sympathicotomy, clipping of sympathetic chain and ramicotomy), dividing the inconstant sympathetic pathways (nerve of Kuntz, ascending or descending rami communicantes) on the second, the third and the fourth ribs will help to get better surgical effect.     

Sequential vein bypass grafting: tactics and long-term results

The sequential bypass grafting technique has many advantages over coronary artery bypass grafting with single grafts. The aim of this study was to evaluate the consequences of sequential bypass graft failure. Between 1 January 1984 and 31 December 1996, 3846 patients underwent primary coronary artery bypass vein grafting. A total of 3490 patients received sequential vein bypass grafts and 356 patients received single vein bypass grafts (9%). There were 6177 sequential bypass grafts (3490 postero-lateral grafts (56%) and 2687 in the antero-lateral position (44%)) and 1468 single grafts (972 vein grafts and 496 internal thoracic artery grafts). Overall, there were 80 hospital deaths (2.1%). Mortality in relation to type of grafts used was: 13 deaths in 356 patients with only single graft (3.7%) and 67 deaths in 3490 patients who received sequential vein grafts (1.9%). Of 3766 hospital survivors, 3731 were followed for an average of 76 months. During follow-up, 85 patients died (2.3%), 15 patients (0.4%) underwent cardiac transplantation and 52 (1.4%) had re-do coronary artery bypass vein grafting. Graft-percutaneous transluminal coronary angioplasty was performed in 56 patients (1.5%), 37/1390 single bypass grafts (2.7%) and 19/6023 sequential bypass grafts (0.3%). There were 272/6023 symptomatic sequential graft occlusions (4.5%) (182 were in postero-lateral position and 90 in the antero-lateral position). There were 66/667 single vein graft occlusions (9.9%) and 15 symptomatic internal thoracic artery graft occlusions (2.1%) during follow-up. In 97% of patients, presenting symptoms of postero-lateral sequential bypass graft occlusion took the form of a renewed angina with a myocardial infarction rate of 3% and a mortality rate of 7%. Corresponding figures for antero-lateral sequential bypass grafts were 22, 78 and 68%, and anterior single vein bypass grafts were 70, 30 and 15%, respectively. The overall 10-year survival rate in patients with sequential bypass grafts was 81.2% and the cumulative patency rate (1464 angio-controls of 2576 sequential vein grafts) was 72.2%. A symptomatic occlusion of a postero-lateral sequential vein bypass results in a low incidence of myocardial infarction with low mortality, when the terminal anastomosis is connected to a high flow vessel. An antero-lateral sequential vein bypass graft has better long-term patency than single vein bypass, but should occlusion occur, it would usually be associated with a higher myocardial infarction and mortality rates than a single vein graft. The highest risk for failure of a sequential graft in the antero-lateral position occurs when the left anterior descending artery (LAD) is small or severely diseased. In this situation the single graft technique with internal thoracic artery appears to be safer.