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We thank Dr Agostini [1Agostini M. A new no-touch aorta technique (letter).Ann Thorac Surg. 2010; 90: 359-360Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] for his interest in our article [2Cirillo M. Messina A. DallaTomba M. et al.A new no-touch aorta technique for arterial source, off-pump surgery.Ann Thorac Surg. 2009; 88: e46-e47Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. The letter of Agostini [1Agostini M. A new no-touch aorta technique (letter).Ann Thorac Surg. 2010; 90: 359-360Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar] underlines the importance to improve less invasive surgical solutions in off-pump coronary artery bypass (OPCAB) surgery. Our aim is to reduce the invasiveness of surgical revascularization whenever possible, independently of the presence (or not) of an untouchable aorta. Not to touch the aorta at all is related to a reduction in cerebral events (0.46% at our Institution; 0.1% in the “no-touch” group, and 0.9% in the “touch” group; p = 0.038), given that side clamping of the aorta at a physiological pressure during OPCAB is even more traumatic and dangerous than clamping under the continuous flow pressure status during on-pump revascularization. The author describes a side-to-end anastomosis between the right internal mammary artery (RIMA) stump and the saphenous vein graft (SVG). We proposed an end-to-end anastomosis between the two conduits at the most proximal level of the RIMA. This solution allows a better matching of the two conduits and assures the maximum direct amount of flow distally. We would like to underline that our technique is neither an elongation technique nor an alternative to currently used mixed grafts. Our technique is a solution to using an intrathoracic source of flow, otherwise lost, to leave the aorta untouched, and to leave the median line free from crossing conduits, without opening another anatomic cavity. We also used this technique in a patient who needed a right graft without isolation of the RIMA to serve as a “Y” graft. In this case we isolated just the first few centimeters of the RIMA, leaving the artery perfused from its superior epigastric artery connections. With this technique, we never again touch any aorta in OPCAB surgery, leaving it completely free from surgical trauma, regardless of whether it is atherosclerotic, calcified, untouchable, or an apparently normal aorta. Furthermore, we hope that the use of an arterial source of flow with a lower dp/dt will lead to a longer life of the venous graft. Until now, we did not experience any occlusion of the composite grafts in the 29 patients who received this surgical solution, and we look forward to report a longer follow-up assessment. A New No-Touch Aorta TechniqueThe Annals of Thoracic SurgeryVol. 90Issue 1PreviewI read the interesting article on a new technique for “no-touch” off-pump coronary artery bypass (OPCAB) surgery by Cirillo and colleagues [1], in which they described the anastomosis of the saphenous vein graft (SVG) to the proximal stump of the right internal mammary artery (RIMA), which is used as a free graft and anastomosed to the left internal mammary artery (LIMA). I was impressed, as we successfully adopted the same technique in 2005, which was influenced by a previous report [2]. Full-Text PDF