BACKGROUND Crossclamping a severely atherosclerotic ascending aorta carries a significant risk of stroke in coronary artery bypass grafting. Besides other techniques aortic no touch concepts are increasingly applied for management of this problem. METHODS Out of 407 patients undergoing epiaortic scanning during coronary artery bypass grafting 38 (9.3%) exhibited severe ascending aortic atherosclerosis. 22 of these patients (18 male, 4 female, age 72 (57-79) years, Parsonnet Score 11 (0-18), Euro Score 8 (2-13), McSPI Stroke Risk Index 6 (1-30) %) were operated on using a beating heart and aortic no touch technique. All patients received at least one internal mammary artery (IMA) in situ graft and additional extraanatomical bypass conduits: venous Y-graft from the IMA (n=14), arterial Y-graft from the IMA (n=3), vein graft from the axillary artery (n=3), vein graft from the IMA stump (n=2), vein graft from the innominate artery (n=2). RESULTS No stroke occurred. The rate of perioperative myocardial infarction (CKMB rt; 50 U/l) was 5/22. Median ICU length of stay was 54 (15-1245) h. Hospital mortality was 2/22. Pre- and postoperative angina class (CCSC) were 3.3 +/- 0.9 and 1.4 +/- 0.9 respectively (p<0.001). After a median follow up period of 8 months 3 deaths, one stroke, and one myocardial infarction occurred. On 3D multislice CT scan reconstructions which were performed in 13 patients during the first postoperative year all IMA grafts to the LAD and 11 out of 13 extraanatomical vein grafts were shown to be patent. CONCLUSIONS Performance of beating heart extraanatomical coronary artery bypass grafts for management of a heavily diseased ascending aorta can result in a very low stroke rate despite a considerable stroke risk. The complexity of the procedures may be reflected by a relatively high rate of perioperative myocardial infarctions. Perioperative mortality as well as short term patency of extraanatomical bypass grafts seem to be acceptable.