Double Coronary Bypass Using the Internal Thoracic Artery

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Scientific illustrations of a double coronary artery bypass, a surgical procedure that redirects blood flow around blockages in the coronary arteries. This page was rendered traditionally with ink.

Client: Professor Michael Corrin, Doctor Vivek Rao
Year: 2020
Media: Horos, Cinema 4D, Adobe Illustrator, Adobe Photoshop, Pencil, Ink

Surgical procedures must be illustrated with extreme precision and attention to detail for residents to learn from them. For this piece, I observed double coronary artery bypass surgeries and consulted with the surgeon to create an accurate sequence of images depicting the procedure the way the surgeon performed it. One page of the sequence was rendered with ink, a widely-used technique for surgical illustration.

Process Work

Sketches from the Operating Room

I took quick notes and sketches in the operating room while the surgery was in progress, a few of which are shown below. Sketches included the blockage and grafting sites along the coronary arteries, surgical tools and how they were used, and the surgical field. Notes included descriptions of the surgery as well as names of tools and techniques used so I could search them up later.

Rough pencil sketches taken while observing the coronary artery bypass surgery in the surgery room. Notes include surgical instruments, sites of anastomoses, surgeon viewpoints, and so on.

First Draft

For the first draft, I focused on understanding the initial and ending states of the surgery, since those would guide understanding of the rest of the procedure. Sketching the procedure informed me I needed to do more research on heart cannulation and the anastomoses used for grafting the internal thoracic artery onto the coronary arteries.

Initial sketches of the double coronary artery bypass surgical procedure. The first and last steps are detailed, while the steps in between are rough, as more research and consultation with the surgeon are needed.

Second Draft

I began to refine and detail the sketches more and combined steps from the first step where possible. Important changes were the addition of a scout image to describe the location of the incision, a more gradual zoom-in between steps 1-3 to maintain context, and clearer, more accurate sketches of the anastomosis suture patterns.

Detailed sketches of the double coronary artery bypass surgery. There is more focus on showing the heart vessels and fat around the surgical site, even when zoomed in. Anastomosis suture patterns are also more detailed.

Third Draft

Before the third draft, I met with the surgeon to clarify details about the heart cannulation and anastomosis suture patterns. Therefore, I was able to create refined sketches that emphasized surgical actions, such as cutting the graft site, making a bite with the needle, and pulling the sutures taut. I also added diagrams to clarify the anastomosis suture patterns.

Highly detailed sketches of the double coronary artery bypass surgery. Surgical actions are emphasized by inclusion of surgical instruments and motion of the vessels and sutures. There are also diagrams clearly showing anastomosis suture patterns.

Final Draft

I continued to refine the sketches and correct small but important details. For example, I showed depth using cast shadow and overlap by double-lining the sutures and using white outlines where appropriate. The needles were changed to an accurate size, the anastomosis suture patterns were confidently finalized, and the altered blood flow was shown using arrows in the final image. This draft is appropriate for final rendering, and steps 7 and 8 were rendered in pen and ink (see gallery at the top of the page).

Final sketches of the double coronary bypass surgery process, showing how the surgeon grafts the internal thoracic artery to two sites on the left anterior descending coronary artery.

References

Academic Sources

Agur, Anne M. R. and Dalley, Arthur F. Grant’s Atlas of Anatomy, 14th ed. Wolters Kluwer: Philadelphia, 2017.
Barner, Hendrick B. “Conduits for Coronary Bypass: Internal Thoracic Artery.” Korean Journal of Thracic and Cardiovascular Surgery, no. 45 (2012): 351-367. https://dx.doi.org/10.5090/kjtcs.2012.45.6.351
Gay, William A. Surgical Practice Illustrated: Atlas of Adult Cardiac Surgery. New York: Churchill Livingstone, 1990.
Gerhard, Ziemer and Haverich, Axel. “Coronary Artery Disease.” In Cardiac Surgery: Operations on the Heart and Great Vessels in Adults and Children, edited by Jochen T. Cremer. 721-742. Springer: Berlin, 2017.
Harlan, Bradley J., Starr, Albert, and Harwin, Fredric M. Manual of Cardiac Surgery, Vol. 1. New York: Springer-Verlag, 1980.
Lytle, Bruce W. “Anastomotic Techniques.” Operative Techniques in Thoracic and Cardiovascular Surgery 5, no. 4 (2000): 222-230. https://doi.org/10.1053/2000.otct.18708
Ochi, Masami. “Graft-Coronary Anastomosis in Off-Pump CABG.” In Off-Pump Coronary Artery Bypass, edited by Tohru Asai, Masami Ochi, and Hitoshi Yokoyama. 121-126. Springer: Tokyo, 2016.
Puskas, John D. “Tips and Techniques for Multivessel OPCAB.” Operative Techniques in Thoracic and Cardiovascular Surgery 11, no. 2 (2006): 78-89. https://doi.org/10.1053/j.optechstcvs.2006.04.001
Rutherford, Robert B. Atlas of Vascular Surgery: Basic Techniques and Exposures. Philadelphia: W. B. Saunders Company, 1993.
Seifert, Patricia C. Mosby’s Perioperative Nursing Series: Cardiac Surgery. St. Louis: Mosby, 1994.
Spray, Thomas L. and Acker, Michael A. Rob & Smith’s Operative Cardiac Surgery, 6th ed. CRC Press: Boca Raton, United State of America, 2019.

Visual References

Anatomography. “Data version 4.3i: Region of wall of heart, Coronary artery, Segment of thoracic aorta, Trunk of left subclavian artery, Trunk of left internal thoracic artery, Set of anterior intercostal veins.” BodyParts3D. Accessed February 10, 2020. https://lifesciencedb.jp/bp3d/
Pixmeo. “AGECANONIX.” OsiriX: DICOM Image Library. Accessed November 18, 2019. https://www.osirix-viewer.com/resources/dicom-image-library/
Scanlan International Inc. “Coronary Artery Bypass Graft Instruments.” Accessed February 20, 2020. https://drive.google.com/drive/u/0/folders/1zF7PABtOcLnIVjU_UKDFa-4stB0wnG_R.
Vo, Anh and Nguyen, Dinh. “Left Internal Mammary Artery Harvesting: The Skeletonization Technique.” CTSNet. Last modified February 13, 2019. https://www.ctsnet.org/article/left-internal-mammary-artery-harvesting-skeletonization-technique.
Wetlabtraining. “Distal Anastomosis: Parachute Technique CCABG Cardiac Surgery.” Filmed August 17, 2011. Video, 5:59. https://www.youtube.com/watch?v=xuSVoNpLp6k