ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michel Carrier
Raymond Cartier
Michel Pellerin
Pierre Pagé
Louis P. Perrault
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chavanon, O.
Right arrow Articles by Perrault, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chavanon, O.
Right arrow Articles by Perrault, L. P.
Related Collections
Right arrow Great vessels
Right arrow Minimally invasive surgery

Ann Thorac Surg 2001;71:117-121
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Increased incidence of acute ascending aortic dissection with off-pump aortocoronary bypass surgery?

Olivier Chavanon, MDa, Michel Carrier, MDa, Raymond Cartier, MDa, Yves Hébert, MDa, Michel Pellerin, MDa, Pierre Pagé, MDa, Louis P. Perrault, MD, PhDa

a Department of Surgery, Research Center, Montreal Heart Institute, Montreal, Quebec, Canada

Accepted for publication May 9, 2000.

Address reprint requests to Dr Perrault, Research Center, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec, Canada H1T 1C8
e-mail: lpperrau{at}icm.umontreal.ca


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. An apparent increase in the incidence of acute ascending aortic dissection following off-pump coronary artery bypass grafting (OPCAB) led us to assess retrospectively the rate and circumstances of this complication in our institution on a consecutive series of patients undergoing aortocoronary bypass performed with and without extracorporeal circulation (ECC).

Methods. A retrospective analysis of acute ascending aortic dissections complicating coronary artery bypass grafting surgery in 3,031 patients in our institution since April 1, 1995, was performed using the database of the Montreal Heart Institute.

Results. There was a greater frequency of hypertension in the OPCAB group. Iatrogenic acute aortic dissection occurred in 3 patients among 308 operated on without ECC (0.97%) and 1 patient among 2,723 operated on under ECC (0.04%). This difference was statistically significant (p < 0.00001).

Conclusions. The risk of aortic dissection may be increased in OPCAB. Careful manipulation of the aorta with a single side-clamping and a control of the arterial pressure should be used to minimize aortic trauma. High-risk patients should undergo CABG without side-clamping of the aorta or CABG with ECC to prevent this redoubtable complication of myocardial revascularization.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Iatrogenic acute aortic dissection (IAAD) is a rare but potentially fatal complication of coronary artery bypass grafting surgery. Its frequency is about 0.12% of cases after open heart surgery with extracorporeal circulation (ECC) [1–3], and can occur intraoperatively or later during the postoperative hospitalization or after discharge [4]. With the new trend of minimally invasive cardiac surgery, and the regained interest for off-pump coronary artery bypass grafting (OPCAB) sparked by recent advances in myocardial stabilization, a number of operative conditions have been modified. An apparent increase in the incidence of acute ascending aortic dissection following OPCAB led us to assess retrospectively the rate and circumstances of this complication in our institution, on a consecutive series of patients undergoing aortocoronary bypass performed with and without ECC.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
A retrospective analysis of acute ascending aortic dissections complicating coronary artery bypass grafting surgery in 3,031 patients in our institution from April 1, 1995, to April 1997 was performed using the joint anesthesiology–surgery database of the Montreal Heart Institute. OPCAB was started in September 1996.

Revascularization with ECC
All ECC were performed under moderate hypothermia (33°C to 34°C) using the usual technique for CABG surgery. After performing distal anastomosis and declamping the aorta, proximal anastomosis were performed with a beating heart using a Beck clamp, placed while decreasing the ECC flow to 500 mL/min which was repeated at the time of side and cross-clamping and unclamping. Proximal anastomoses were done using 5-0 polypropylene.

Off-pump coronary artery bypass
In the early experience, patients were selected according to specific anatomic criteria: primary surgery, vessels greater than 1.5 mm in diameter. With increasing experience, indications were broadened to most patients, including the circumflex artery territory providing there were no intramyocardial arteries. The operative technique has been previously described [5, 6]. Briefly, a mechanical stabilizer system was used with the pressure-fixation concept. Patient positioning and pharmacologic management using either intravenous nitroglycerin infusion or vasopressor drugs, allowed stabilization of hemodynamics during positioning of the heart for anastomoses. The left internal mammary artery was grafted to the left anterior descending coronary artery (LAD) in the majority of patients (Table 1). Proximal anastomoses were performed in the same manner as with ECC except no decrease of arterial pressure was induced at the time of application of the side-clamp or when declamping for the first 100 patients, then systemic pressure reduction to 100 mm Hg was done in the following 208 patients. In the initial experience, distal and proximal anastomosis were done sequentially for each saphenous vein graft (SVG) necessitating multiple periods of side-clamping for multiple SVG.


View this table:
[in this window]
[in a new window]
  		Table 1. Preoperative Data

 
Statistics
Results are expressed as mean ± standard deviation. For categorical variables, groups were compared using the Pearson’s {chi}2 test. For continuous variables, the Fisher’s exact test was used.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
Demographic data are presented in Table 1. There were no statistically significant differences between the 2 groups except for history of stroke and number of grafts. Postoperative results are presented in Table 2.


View this table:
[in this window]
[in a new window]
  		Table 2. Postoperative Data

 
IAAD occurred in 3 patients among 308 operated on without ECC (0.97%) and 1 patient among 2,723 operated on under ECC (0.04%). This difference was statistically significant (p < 0.00001). Operative data and outcome of IAAD are summarized in Tables 3 and 4. In all cases, 2 SVG were performed, and proximal anastomoses used separate periods of aortic side-clamping, except in case 1. In this case, because of a dilated ascending aorta, a Y-graft was performed to minimize the trauma because of aortic side-clamping. Aortic dissection (AD) occurred intraoperatively in 2 cases (cases 2 and 4), and were treated by immediate aortic replacement with a Dacron (C.R. Bard, Haverhill, MA) graft under cardiopulmonary bypass to which the SVG were anastomosed in a Y-graft manner. Both patients were discharged and did well. The side-clamping in the ECC patient was performed with a blood pressure of 90 mm Hg. In the 2 other patients (cases 1 and 3), aortic dissection occurred postoperatively and had an unfavorable outcome. In patient 1, AD was diagnosed on postoperative day 13 and was promptly brought to surgery, during which extreme operative difficulties were encountered because of severe adhesions and inflammation. Repair with graft interposition was performed under circulatory arrest but weaning of ECC was not tolerated and the patient died of cardiac failure. In patient 3, cardiorespiratory arrest occurred on postoperative day 5, and AD was diagnosed on postmortem examination. In all cases, macroscopic lesions from aortic side-clamping were present (Figs 1 and 2). In 3 of them, microscopic examinations were performed (Fig 3) (cases 2–4) and showed degeneration of the elastic lamella in 2 cases (cases 2 and 4), and cystic medial necrosis in 1 (case 2) (Fig 4). Three patients had a history of hypertension and 1 was associated with dilatation of the ascending aorta at the time of surgery. In the other patient (case 4), the aorta was found to be friable at the time of surgery.


View this table:
[in this window]
[in a new window]
  		Table 3. Patient Clinical Parameters and Operative Data During Coronary Artery Bypass Surgery

 

View this table:
[in this window]
[in a new window]
  		Table 4. Operative Data and Outcome of Iatrogenic Aortic Dissection

 


View larger version (84K):
[in this window]
[in a new window]
  		Fig 3. Histological examination showing the laceration of the aortic wall in dissection of the ascending aorta after off-pump coronary artery bypass surgery (Movat pentachrome stain, original magnification x 10).

 


View larger version (141K):
[in this window]
[in a new window]
  		Fig 4. Microscopic examination showing aortic cystic degeneration of the elastic lamellae and smooth muscle cells with Movat pentachrome staining in the ascending aorta in the same patient (original magnification x 200).

 


View larger version (109K):
[in this window]
[in a new window]
  		Fig 1. Intimal trauma after application of aortic sideclamp.

 


View larger version (110K):
[in this window]
[in a new window]
  		Fig 2. Aortic laceration at the site of proximal anastomosis resulting in aortic dissection and death on postoperative day 5 after off-pump coronary artery bypass.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
The incidence of acute ascending aortic dissection following heart surgery is low with a rate of about 0.12% [1–3]. Among 8,624 cardiac operations with ECC, 10 patients presented with a IAAD, of whom 8 were after CABG including 2 with concomitant valvular surgery [3]. Intraoperative dissection was predominant over postoperative occurrence [2–4]. Acute aortic dissection (AAD) can also occur later after the initial CABG [7, 8], although in some cases the mediastinum may be enlarged on the postoperative chest x-ray film after CABG [9] as in one of our patients. Prompt recognition and surgical repair are essential to achieve a successful outcome, although in some cases long-term survival without surgery has been reported [10]. In most observations and in our series, predisposing factors can be identified such as a history of hypertension [9], atherosclerosis of the aorta, thin dilated aortic walls, cystic medial necrosis, or inherited disorders of connective tissue, as in spontaneous aortic dissection. In the case of IAAD, the surgical trauma is the main trigger mechanism in conjunction with pathological conditions of the aorta that are often present in the population undergoing CABG surgery. Many manipulations may be the initiating point of the dissection [2, 11]: aortic cannulation; injury at the time of application of the cross-clamp, or the side-clamp, creating an intimal tear; and direct injury during suturing of the graft to the aorta, or failure to obtain intima-to-intima approximation. Because OPCABG does not necessitate cannulation and aortic cross-clamping, the risky manipulations are from lateral clamping that may increase the risk of injury because of the pulsatile pattern of arterial pressure. Indeed, uncontrolled hypertension is a major risk factor in the occurrence of aortic clamp trauma [2]. Furthermore, in conventional CABG, ECC allows the temporary decrease in arterial pressure, which is nonpulsatile, to a safe threshold (50 mm Hg) while clamping the aorta, facilitating the placement of the clamp and diminishing the likelihood of aortic clamp injury and slippage. This important maneuver is not as readily feasible during OPCAB and lateral clamping may be hazardous when predisposing factors coexist. Consequently, decreasing the arterial pressure at the time of application and removal of the aortic side-clamp, with or without temporary partial clamping of the inferior vena cava [12], and maintaining a low systolic arterial pressure (about 100 mm Hg) during the proximal anastomoses with pharmacological agents may minimize the strain caused by the clamp on the aorta. Another preventive measure, which may be useful even under ECC, includes the use of a single side-clamping period for performance of proximal anastomoses. Another alternative is to perform proximal anastomosis during a single cross-clamp period as is recommended in reoperative CABG surgery. If multiple SVG are used in OPCAB, we now perform both proximal anastomoses after the first distal anastomosis using a SVG, then the second distal anastomosis is completed. If more than two SVG grafts are necessary, Y-grafts with venovenous anastomosis are performed with a running 7-0 polypropylene suture.

Avoidance of the greater curvature of the aorta, a classical site of dissection, for placement of the proximal anastomosis, and preference for the inner portion of the aorta after dissection of the aortopulmonary space, may decrease the risk of complications. Sequential grafting may also be used to decrease the number of proximal anastomosis. In high-risk situations where there is underlying disease of the aorta, the proximal anastomosis can be performed on the brachiocephalic artery, or in a end-to-side manner to the internal mammary artery [13]. Total arterial revascularization using bilateral pedicled mammary artery and gastroepiploic artery could be an ideal alternative technique in such cases avoiding manipulation of the aorta altogether [14]. When the aorta is thin or dilated, elective use ECC for CABG may be preferable allowing performance of proximal anastomosis during a single aortic cross-clamp time, or may allow a complementary procedure on the aorta if required. Assessment of aortic disease with epicardial echography may also be useful in diagnosing aortas at high risk of dissection [15, 16].

When AAD occurs, establishment of the diagnosis intraoperatively is preferable and associated with a better prognosis because it permits proceeding to immediate repair by either interposition of a prosthesis [3] or local repair as in 4 of 6 patients in Blakeman and coworkers’ series [1] and in 11 of 20 cases in the report of Still and colleagues [2]. Postoperatively, the diagnosis may be suspected by a persistently widened mediastinum, recurrence of chest pain, peripheral ischemic changes or more subtle visceral ischemic damage leading to a gradual rise of lactic acid and urea-creatinine ratio. Prompt transesophageal echocardiography allows confirmation of the diagnosis, avoids delays in therapeutic care, and guides surgical strategy. Early postoperative AAD generally requires graft replacement of the ascending aorta [1]. In case of late type A dissection, local repair was feasible in only 2% of the cases in the series of Gillinov and associates [8]. Patent vein grafts can be reattached with an "island flap" of ascending aorta to the prosthesis, or a new saphenous vein either interposed or as a new bypass can be used [8]. Postoperative mortality ranges from 15% to 50% [2, 3, 8]. To avoid this high mortality rate, alternative techniques have been proposed such as extra-anatomic bypass [17] or catheter fenestration with stenting, but some concerns remain about the evolution of the dissected ascending aorta.

Limitations
The influence of the learning curve on this complication cannot be ruled out. The small amount of events in both groups make absolute conclusions about the relationship between OPCAB and an increased incidence of dissection difficult to establish as does the lack of prospective follow-up. However, the careful statistical analysis of this consecutive cohort of patients spreads the underreporting bias across both groups. No dissections have been identified since the end of the study period which may be explained by an increasing experience in modifying the surgical technique (avoiding cross-clamping) in high-risk patients and using precautions as mentioned above.

Conclusion
Aortic dissection after coronary artery bypass grafting surgery maybe more frequent in OPCAB than with the traditional technique under ECC. This suspicion should be verified with a long-term follow-up study of patients undergoing OPCAB along with the patency assessment of graft performed with this technique. Meanwhile, attention should be given to technical details that may influence the occurrence of IAAD. Careful manipulation of the aorta with a single side-clamping and control of the arterial pressure should be used to minimize aortic trauma. Patients at risk for this complication should undergo alternative techniques without side-clamping of the aorta, or undergo CABG with ECC, to prevent this redoubtable complication.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Dr André Couturier for expert statistical analysis, and Dr Tack Ki Leung for pathological examination of the specimens.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Blakeman B.M., Pifarre R., Sullivan H.J., et al. Perioperative dissection of the ascending aorta: types of repair. J Card Surg 1988;3:9-14.[Medline]
  2. Still R.J., Hilgenberg A.D., Akins C.W., Daggett W.M., Buckley M.J. Intraoperative aortic dissection. Ann Thorac Surg 1992;53:374-379.[Abstract]
  3. Ruchat P., Hurni M., Stumpe F., Fischer A.P., von Segesser L.K. Acute ascending aortic dissection complicating open-heart surgery: cerebral perfusion defines the outcome. Eur J Cardiothorac Surg 1998;14:449-452.[Abstract/Free Full Text]
  4. Murphy D.A., Craver J.M., Jones E.L., et al. Recognition and management of ascending aortic dissection complicating cardiac surgical operations. J Thorac Cardiovasc Surg 1983;85:247-256.[Abstract]
  5. Cartier R. Systematic off-pump coronary artery revascularization: experience of 275 cases. Ann Thorac Surg 1999;68:1494-1497.[Abstract/Free Full Text]
  6. Dagenais F., Perrault L.P., Cartier R., et al. Beating heart coronary artery bypass grafting: technical aspects and results in 200 patients. Can J Cardiol 1999;15:867-872.[Medline]
  7. Yaku H., Fermanis G.G., Macauley J., Horton D.A. Dissection of the ascending aorta: a late complication of coronary artery bypass grafting. Ann Thorac Surg 1996;62:1834-1835.[Abstract/Free Full Text]
  8. Gillinov A.M., Lytle B.W., Kaplon R.J., Casselman F.P., Blackstone E.H., Cosgrove D.M. Dissection of the ascending aorta after previous cardiac surgery: differences in presentation and management. J Thorac Cardiovasc Surg 1999;117:252-260.[Abstract/Free Full Text]
  9. Bopp P., Perrenoud J.J., Periat M. Dissection of ascending aorta. Rare complication of aortocoronary venous bypass surgery. Br Heart J 1981;46:571-573.[Abstract/Free Full Text]
  10. Horowitz R.S., Kitchen J.G., III Aortic dissection following coronary arterial bypass graft surgery. Chest 1981;80:749-751.[Abstract/Free Full Text]
  11. Connolly M.W. Aortoatriocaval cannulation for cardiopulmonary bypass. In: Mora C.T., ed. Cardiopulmonary bypass. Principles and techniques of extracorporeal circulation. New York: Springer-Verlag, 1995:257-263.
  12. Dagenais F., Cartier R. Pulmonary hypertension during beating heart coronary surgery: intermittent inferior vena cava snaring. Ann Thorac Surg 1999;68:1094-1095.[Abstract/Free Full Text]
  13. Peigh P.S., DiSesa V.J., Collins J.J., Jr, Cohn L.H. Coronary bypass grafting with totally calcified or acutely dissected ascending aorta. Ann Thorac Surg 1991;51:102-104.[Abstract]
  14. Calafiore A.M., Teodori G., Di Giammarco G., et al. Multiple arterial conduits without cardiopulmonary bypass: early angiographic results. Ann Thorac Surg 1999;67:450-456.[Abstract/Free Full Text]
  15. Baribeau Y.R., Wesbrook B.M. Intraoperative epicardial echocardiography. In: Izzat M.B., Sanderson J.E., St. John Sutton M.G., eds. Echocardiography in adult cardiac surgery. Oxford, UK: ISIS Medical Media Ltd, 1999:223-229.
  16. Wareing T.H., Davila-Roman V.G., Barzilai B., Murphy S.F., Kouchoukos N.T. Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment. J Thorac Cardiovasc Surg 1992;103:453-462.[Abstract]
  17. Pappas D., Hines G.L., Gennaro M., Hartman A. Delayed iatrogenic aortic dissection from coronary bypass managed with extraanatomic bypass. J Thorac Cardiovasc Surg 1998;115:947-949.[Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. Weber, R. Tavakoli, J. Gruenenfelder, and M. Genoni
Ascending aortic dissection after proximal bypass anastomotic device.
J. Thorac. Cardiovasc. Surg., November 1, 2008; 136(5): 1364 - 1365.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
K. Kotoh, K. Fukahara, T. Doi, S. Nagura, and T. Misaki
Predictors of Early Postoperative Cerebral Infarction After Isolated Off-Pump Coronary Artery Bypass Grafting
Ann. Thorac. Surg., May 1, 2007; 83(5): 1679 - 1683.
[Abstract] [Full Text] [PDF]

Home page
 ICVTSHome page
T. Fleck, M. Ehrlich, M. Czerny, E. Wolner, M. Grabenwoger, and M. Grimm
Intraoperative iatrogenic type A aortic dissection and perioperative outcome
Interactive CardioVascular and Thoracic Surgery, February 1, 2006; 5(1): 11 - 14.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. Zinkernagel, M. J. Wilhelm, R. Tavakoli, M. I. Turina, and M. Genoni
Aortic Dissection With Potential Origin From a Mechanical Bypass Anastomosis
Ann. Thorac. Surg., July 1, 2005; 80(1): 316 - 318.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
B. Akpinar, M. Guden, E. Sagbas, I. Sanisoglu, M. U. Ergenoglu, and C. Turkoglu
Clinical experience with the Novare Enclose II manual proximal anastomotic device during off-pump coronary artery surgery
Eur. J. Cardiothorac. Surg., June 1, 2005; 27(6): 1070 - 1073.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. Athanasiou, O. Aziz, R. Casula, and B. Glenville
Reply
Ann. Thorac. Surg., December 1, 2004; 78(6): 2212 - 2213.
[Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
S. Martens, M. Dietrich, C. Herzog, M. Doss, G. Schneider, A. Moritz, and G. Wimmer-Greinecker
Automatic connector devices for proximal anastomoses do not decrease embolic debris compared with conventional anastomoses in CABG
Eur. J. Cardiothorac. Surg., June 1, 2004; 25(6): 993 - 1000.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
K. Okada, T. Sueda, K. Orihashi, and K. Imai
Early type A dissection with the aortic connector device
Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 902 - 904.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
T. P. Carrel, F. S. Eckstein, L. Englberger, P. A. Berdat, and J. Schmidli
Clinical experience with devices for facilitated anastomoses in coronary artery bypass surgery
Ann. Thorac. Surg., March 1, 2004; 77(3): 1110 - 1120.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Chavanon, M. Abdennadher, and D. Blin
Off-pump coronary artery bypass grafting using arterial grafts exclusively: aiming for an absolute "no-touch" aortic technique
Ann. Thorac. Surg., January 1, 2004; 77(1): 379 - 380.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
J. T. Reston, S. J. Tregear, and C. M. Turkelson
Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting
Ann. Thorac. Surg., November 1, 2003; 76(5): 1510 - 1515.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
D. L. Ngaage
Off-pump coronary artery bypass grafting: the myth, the logic and the science
Eur. J. Cardiothorac. Surg., October 1, 2003; 24(4): 557 - 570.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
J.-M. De Smet and C. Stefanidis
Acute aortic dissection after off-pump coronary artery surgery
Eur. J. Cardiothorac. Surg., August 1, 2003; 24(2): 315 - 317.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. J. Mack, R. W. Emery, L. R. Ley, P. A. Cole, A. Leonard, J. R. Edgerton, T. M. Dewey, M. J. Magee, and T. S. Flavin
Initial experience with proximal anastomoses performed with a mechanical connector
Ann. Thorac. Surg., June 1, 2003; 75(6): 1866 - 1871.
[Abstract] [Full Text] [PDF]

Home page
 Card Surg AdultHome page
T. M. Dewey and M. J. Mack
Myocardial Revascularization Without Cardiopulmonary Bypass
Card. Surg. Adult, January 1, 2003; 2(2003): 609 - 625.
[Full Text]

Home page
 Ann. Thorac. Surg.Home page
T. Shimokawa, N. Minato, N. Yamada, Y. Takeda, Y. Hisamatsu, and M. Itoh
Assessment of ascending aorta using epiaortic ultrasonography during off-pump coronary artery bypass grafting
Ann. Thorac. Surg., December 1, 2002; 74(6): 2097 - 2100.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Chavanon, M. Durand, R. Hacini, H. Bouvaist, M. Noirclerc, T. Ayad, and D. Blin
Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass
Ann. Thorac. Surg., February 1, 2002; 73(2): 499 - 504.
[Abstract] [Full Text] [PDF]

Home page
 CirculationHome page
M. Yacoub
Off-Pump Coronary Bypass Surgery: In Search of an Identity
Circulation, October 9, 2001; 104(15): 1743 - 1745.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
Z. S. Meharwal and N. Trehan
Aortocoronary bypass surgery and ascending aortic dissection: letter 2
Ann. Thorac. Surg., October 1, 2001; 72(4): 1445 - 1445.
[Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
O. Chavanon and L. P. Perrault
Aortocoronary bypass surgery and ascending aortic dissection: Reply
Ann. Thorac. Surg., October 1, 2001; 72(4): 1445 - 1446.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Michel Carrier
Raymond Cartier
Michel Pellerin
Pierre Pagé
Louis P. Perrault
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chavanon, O.
Right arrow Articles by Perrault, L. P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chavanon, O.
Right arrow Articles by Perrault, L. P.
Related Collections
Right arrow Great vessels
Right arrow Minimally invasive surgery

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS