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Ann Thorac Surg 2001;72:1378-1380
© 2001 The Society of Thoracic Surgeons

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Case report

Management of porcelain aorta and calcified great vessels in coronary artery bypass grafting with off-pump and no-touch technology

^a Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, Minnesota, USA

Accepted for publication October 30, 2000.

Address reprint requests to Dr Bittner, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Box 207 Mayo, 420 Delaware St, Minneapolis, MN 55455
e-mail: bittn006{at}tc.umn.edu

	Abstract

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A 69-year-old woman presented with postinfarct unstable angina and decreased ventricular function secondary to significant left main coronary artery stenosis in combination with total right coronary artery occlusion. We did successful off-pump coronary revascularization in this patient with severely calcified ascending aorta and great vessels, subtotal aortobiiliac stenoses, a history of previous stroke, and right carotid endarterectomy.

	Introduction

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The significance of atheroemboli from severe ascending aortic atherosclerosis and the associated extraordinarily high incidence of cerebral vascular accidents (CVA) after cannulation and clamping of the aorta are well documented. Mills and Everson [1] observed a CVA rate of 45%, with four fatal strokes in a series of 20 patients with severe aortic atherosclerosis. On the basis of those findings, we believe that modifications of standard cardiovascular techniques are mandatory in order to avoid manipulations and to prevent atheroembolism from the atherosclerosis of the ascending aorta.

A 69-year-old woman was referred for emergent coronary revascularization after she had an acute myocardial infarction with subsequent postinfarct angina. Her medical and surgical histories were remarkable for a 20-year history of stable angina, chronic renal insufficiency with a creatinine of 1.9 mg/dL, recent CVA with mild left-sided hemoplegia, right radical mastectomy with chest wall resection and radiation treatment, right internal carotid endarterectomy, severe lower extremity claudication, and Leriche syndrome due to bilateral aortobiiliac-femoral artery stenoses of 95% to 99%. Cardiac catheterization was done through the left brachial artery. It showed moderately decreased cardiac function with an ejection fraction of 45%, 90% left main coronary artery stenosis with a significant proximal lesion of the left anterior descending artery, 75% proximal left circumflex artery narrowing, and total occlusion of the right coronary artery. A portable chest X-ray showed a slightly enlarged cardiac silhouette and calcified aortic arch structures.

The greater saphenous vein was harvested from both thighs, and a median sternotomy was done. The left internal thoracic artery was dissected and mobilized over its entire length. The left internal thoracic artery was very small in diameter distally, and patchy calcifications were visible and palpable. Inspection and palpation of the anterior mediastinum revealed a severely calcified ascending aorta with extension into the aortic arch and great vessels. The upper part of the midline incision was expanded into the anterior cervical region to dissect the great vessels. A soft area was found on the anterior aspect at the base of the right common carotid artery. This location was selected as the arterial inflow site to which the greater saphenous vein was grafted end-to-side (Fig 1). In preparation for off-pump coronary revascularization, the right side of the sternum was elevated approximately 30 to 35 degrees, the right-sided pericardial-pleural structures were incised vertically at the level of the inferior vena cava under protection of the right phrenic nerve, and the operation table was rotated to the right. Tension on the previously placed deep pericardial sutures rotated the entire heart toward the surgeon’s side, and the left anterior descending artery and first obtuse marginal artery became near midline structures. Tension on the deepest pericardial sutures led to elevation of the cardiac apex and herniation through the open chest allowing full exposure of the posterior descending artery.

View larger version (32K): [in this window] [in a new window]   Fig 1. Illustration of the off-pump procedure performed. A composite saphenous vein graft was used as a main inflow conduit and anastomosed end-to-side to the proximal right common carotid artery (CCA). The free left internal artery (LITA) was anastomosed to the left anterior descending artery, and the distal end of the composite graft anastomosed end-to-side to the obtuse marginal branch. A second saphenous vein graft segment was used to bypass the posterior descending artery (PDA).

	Comment

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Various techniques have been described to reduce the risk of atheroembolism causing devastating neurologic defects and strokes in patients with calcified ascending aortas. These techniques include complete arterial revascularization with hypothermic fibrillatory arrest in combination with cannulation of distal arterial sites [2] and use of the innominate or axillary arteries [2, 3]. Wareing and colleagues [4] described femoral artery cannulation and replacement of the ascending aorta with a tube graft during hypothermic cardiac arrest without aortic clamping. The vein grafts were anastomosed to the tube graft. However, none of those techniques eradicated the risk of debris dislocation, embolization, and postoperative morbidity and mortality, because none eliminated manipulation of the diseased aorta. The only strategy potentially capable of eliminating the risk of manipulation-induced stroke in patients with atherosclerotic aorta is the avoidance of cardiopulmonary bypass and clamping of the aorta. In this report we are describing off-pump coronary revascularization in a patient with porcelain aorta and calcified great vessels where an inflow saphenous vein—internal thoracic artery—saphenous vein composite graft was used in a no-touch technique of the ascending and transverse aorta.

Although the indication for beating heart operation is not yet clearly defined, we believe that patients benefitting the most from this technology are those who are at a higher morbidity and mortality risk because of significant comorbidity. We and others [5, 6] demonstrated excellent outcomes after off-pump coronary revascularization in patients with high Parsonnet scores from characteristics such as age greater than 75 years, reduced ejection fraction, acute myocardial infarction, left main disease, history of CVA, and peripheral vascular and internal carotid arterial disease. The patient described in this report had more risk features, including left main stenosis, peripheral vascular disease, and history of CVA for on-pump coronary artery operations. In beating heart operations, cerebral embolic load is reduced by avoiding the embolic potential associated with aortic cannulation and decannulation and with generation of microgaseous and microparticulate emboli from the pump circuit. As a result of the jet of perfusate through the aortic cannula scouring the atherosclerotic aortic lumen, maintenance of more normal aortic flow patterns during beating heart operations would be expected to further decrease the incidence of cerebral and systemic atheroemboli [7]. These factors provide a sound rationale for the investigation of alternative surgical approaches and off-pump technology in certain patients.

	References

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1. Mills N.L., Everson C.T. Atherosclerosis of the ascending aorta and coronary artery bypass: pathology, clinical correlates, and operative management. J Thorac Cardiovasc Surg 1991;102:546-553.[Abstract]
2. Leyh R.G., Bartels C., Notzold A., Sievers H.H. Management of porcelain aorta during coronary artery bypass grafting. Ann Thorac Surg 1999;67:986-988.[Abstract/Free Full Text]
3. Baribeau R.Y., Westbrook B.M., Charlesworth D.C., Maloney C.T. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg 1998;66:33-37.[Abstract/Free Full Text]
4. Wareing T.H., Davila-Roman V.G., Barzilai B., Murphy S.F., Kouchoukos N.T. Management of the severly atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg 1992;103:453-462.[Abstract]
5. Bittner H.B., Mischen T., McKeown P.P., Lucke J.C. Off-pump coronary artery bypass grafting in high risk patients. Cardiothorac Techniques Technol 2000;6:104.
6. Del Rizzo D.F., Boyd W.D., Novick R.J., McKenzie F.N., Desai N.D., Menkis A.H. Safety and cost-effectiveness of MIDCABG in high-risk CABG patients. Ann Thorac Surg 1998;66:1002-1007.[Abstract/Free Full Text]
7. Murkin J.M. Neurologic injury during coronary revascularization: etiology and management. Adv Cardiac Surg 1998;10:75-113.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hartmuth B. Bittner Michael A. Savitt Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bittner, H. B. Articles by Savitt, M. A. Search for Related Content PubMed PubMed Citation Articles by Bittner, H. B. Articles by Savitt, M. A. Related Collections Lung - transplantation