What you can't see can fail your graft

An intramural LAD is one of the more demanding scenarios in CABG. The vessel is there, but it's hidden.

Preoperative angiography maps the coronary tree, but it doesn't tell you how deep a target sits beneath the epicardial surface. When your LAD is tunneled into the myocardium, the anastomotic site requires precise localization before you can plan incision depth, avoid unnecessary tissue injury, and confirm vessel quality. Without intraoperative imaging, you're relying on indirect cues and experience alone.

Hayakawa et al. reported that 10 out 89 consecutive patients had intramural coronary targets — a proportion significant enough to warrant a systematic imaging strategy in every CABG list. ¹

REQUEST Study - LAD at 6 mm depth. Clean walls. A confident anastomosis.

In this case from the REQUEST Study, the target site was an intramural LAD. The surgeon scanned the vessel before incision using the Medistim L15 high-frequency ultrasound imaging probe and the anatomy became immediately clear.

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Patient & Imaging Summary

• Patient: 80-year-old male
• BMI: 25.6
• Target vessel: Intramural LAD
• Depth detected: ~6 mm (proximal wall)
• Lumen diameter: ≥ 1.5 mm
• Vessel wall: Clean, no plaque or calcification

• ‍HFUS localised the LAD at 6 mm depth - a vessel that would have been missed or required blind dissection without imaging.
• Lumen diameter ≥ 1.5 mm and clean vessel walls confirmed this was an ideal anastomotic site - no surprises at the time of incision.‍
• Anastomosis confirmed patent on intraoperative imaging. TTFM assessment showed good flow and a low pulsatility index.