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We appreciate and thank Kim and colleagues [1Kim J.H. Choi J.B. Kuh J.H. Eight-stitch side-to-side anastomosis for sequential coronary artery bypass grafting.Ann Thorac Surg. 2017; 103 (letter): 2020Abstract Full Text Full Text PDF Scopus (1) Google Scholar] for their comments on our article [2Tashiro T. Wada H. Minematsu N. et al.Four-stitch side-to-side anastomosis for sequential coronary bypass grafting.Ann Thorac Surg. 2015; 99: 1092-1094Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. Sequential bypass (SB) is an effective technique for implementing complete revascularization of these complex coronary lesions because it allows a single graft to be used for bypass in several locations. We used a simple SB technique to develop a four-stitch side-to-side anastomosis (4-SSSA). In an experimental study using animals, Shioi [3Shioi K. A study of sequential anastomoses in aortocoronary bypass surgery; internal configurations by the casting injection technique.Nagoya J Med Sci. 1984; 46: 19-26PubMed Google Scholar] compared various techniques to perform anastomoses, reporting that interrupted sutures facilitated a larger anastomotic opening than a continuous suture. In the our study, the 4-SSSA technique, which involves interrupted sutures and a crossed side-to-side anastomosis, facilitated a sufficiently large anastomotic opening. In addition, the excellent postoperative graft patency (96.9% in radial artery, 90.0% in saphenous vein graft) of the 4-SSSA demonstrated it to be a simple and effective anastomotic technique. It is necessary to establish a large anastomotic opening for diamond-shaped side-to-side anastomosis, but a size exceeding the arterial diameter is not necessary. Furthermore, an excessively large anastomotic opening may cause stenosis related to graft flattening. A maximum diameter that does not exceed the coronary diameter is optimal, as is the size of an anastomotic opening. In side-to-side anastomosis, the size of the anastomotic opening is markedly smaller than for end-to-side anastomosis. In our 4-SSSA series, the incisions in the radial artery or target coronary artery were 2 to 3 mm, and those in the saphenous vein graft were 3 mm. To achieve favorable patency, it is necessary to maintain an anastomotic opening as a smooth luminal margin but not as a raw luminal margin. When the stitch-to-stitch interval is enlarged, a raw luminal margin may be formed between the stitches. However, in the 4-SSSA technique, a small incision (2 to 3 mm) is prepared, and the stitch-to-stitch distance is short; there may be no raw luminal margin. Eight-Stitch Side-to-Side Anastomosis for Sequential Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 103Issue 6PreviewWe read with interest the report from Tashiro and colleagues [1] describing their diamond-shaped, four-stitch, side-to-side anastomosis for sequential coronary artery bypass grafting. Most studies have used continuous eight-stitch techniques for sequential side-to-side anastomosis. However, we have found that the continuous suture technique results in a marked purse-string effect (Fig 1A); therefore, we also prefer the interrupted suture technique to obtain a sufficient anastomotic opening. The authors’ interrupted four-stitch technique also avoids the purse-string effect and is efficient. Full-Text PDF