Intra-myocardial LAD: Is it a contraindication for off-pump coronary artery bypass grafting?

The left anterior descending artery (LAD) is the most important vessel in coronary artery bypass graft surgery (CABG). During CABG, LAD may be intra-myocardial for variable distances and depths. This forms a challenge during LAD exposure and anastomosis. The aim was to revise the performed CABG cases to elicit what was the incidence of intramyocardial LAD (IMLAD) among all CABGs, to have an idea about the approaches to the IMLAD and the technique of anastomosis of left internal mammary artery (LIMA) to IMLAD off-pump (OPCAB) and to evaluate the validity and reliability of the off-pump for the IMLAD. Since September 2008 till May 2017; the data of 1138 Off-Pump CABGs were revised. 923 patients had epicardial LAD and it was visible and easily identified throughout 80% of its length; this was group A. 215 (18.89%) patients had IMLAD; they were referred to as group B. There were no statistical significant differences between both groups as regards the age, the sex, the risk factors or the duration of surgery. The post operative bleeding, ischemia, CCU stay and hospital stay were not statistically significant. Conversion to on-pump for the mere presence of an intramyocardial LAD was zero%, but it was 1.3% in group A and 1.86% in B due to hemodynamic instability during manipulations (statistically insignificant). The incidence of IMLAD was 18.89%. IMLAD was a real technical challenge. It was not impossible for exposure and anastomosisas off-pump. The IMLAD is not a contraindication for OPCAB.