Ann Thorac Surg 2006;82:2298-2300
© 2006 The Society of Thoracic Surgeons
Case Reports
Left Common Carotid Artery as Inflow Site in Coronary Artery Bypass Grafting
Marco Agrifoglio, MD, PhD,
Fabio Barili, MD*,
Massimo Porqueddu, MD,
Samer Kassem, MD,
Luca Dainese, MD,
Giulio Pompilio, MD, PhD,
Alessandro Parolari, MD, PhD,
Paolo Biglioli, MD
Department of Cardiac Surgery, Centro Cardiologico Monzino, University of Milan, Milan, Italy
Accepted for publication April 6, 2006.
* Address correspondence to Dr Barili, Department of Cardiac Surgery, University of Milan, Centro Cardiologico Monzino IRCCS, Via Parea 4, Milan, 20138 Italy. (Email: fabarili{at}libero.it).
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Abstract
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Porcelain aorta is associated to significantly increased risk of atheromatous embolization in patients who undergo cardiac surgery. We described three cases in which coronary artery bypass grafting was performed off-pump and the saphenous vein graft was anastomosed proximally to the left common carotid artery. This technique permitted avoidance of ascending aortic manipulation and reduce the risk of atheromatous embolization.
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Introduction
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Porcelain aorta is associated to significantly increased risk of atheromatous embolization in patients who undergo coronary artery bypass grafting [1]. Hence ascending aorta should not be manipulated in these cases.
Off-pump extra-anatomical coronary artery bypass grafts represent an alternative technique to avoid clamping of a severely atherosclerotic ascending aorta and reduce the rate of stroke [2]. Previous studies described the use of the great saphenous vein (GSV) graft from the axillary artery and from the right common carotid artery, as well as Y-grafts from the left internal thoracic artery, with a low rate of perioperative stroke [2–5].
We reported three cases in which coronary artery bypass grafting was performed by off-pump coronary artery bypass grafting and extra-anatomical conduits were anastomosed on the left common carotid artery (LCCA).
From January 1999 to January 2006, 3 patients (2 men and 1 woman) were referred for elective myocardial revascularization. The mean age was 75.7 ± 2.5 years. The mean left ventricular ejection fraction was 65.3% ± 7.5%. The mean preoperative EuroSCORE was 7.3 ± 2.1 (range, 5–9). Coronary angiogram revealed two-vessel coronary artery disease (not eligible to percutaneous intervention) in all patients. A chest roentgenogram documented a calcified ascending aorta and aortic arch. Doppler ultrasonography excluded hemodynamically significant stenoses of the extracranial carotid arteries.
Coronary artery bypass grafting was performed through a median sternotomy with the same off-pump technique in all 3 patients. The left internal thoracic artery and the GSV were harvested; we preferred not to harvest the right internal thoracic artery as patients had type-1 diabetes. The left internal thoracic artery had a small diameter and was not suitable for a Y-graft. Direct intraoperative evaluation confirmed a severe atherosclerotic disease of the ascending aorta involving the aortic arch and the innominate artery. A soft area was found on the anterior portion at the base of the LCCA, and this location was selected as the proximal arterial inflow site for the saphenous vein graft (Fig 1). Off-pump coronary artery bypass grafting was performed by means of a suction stabilizer device (Octopus, Medtronic, MN), deep pericardial traction stitches, and intracoronary shunts (Medtronic).
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Fig 1. Illustration of the extra-anatomical off-pump coronary artery bypass grafting procedure performed. The in situ left internal thoracic artery was anastomosed to the left descending artery. The left common carotid artery was used as an arterial inflow site for the great saphenous vein graft.
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First, the in situ left internal thoracic artery was anastomosed to the left descending artery. After dissection of the proximal part of the LCCA, the GSV graft was proximally anastomosed to the LCCA using 6-0 Prolene running sutures (Ethicon, Somerville, NJ). This anastomosis was constructed using a partial occlusion clamp on the anterior portion of the LCCA and controlling the distal LCCA pulse through palpation to avoid cerebral ischemia. The distal end of the GSV graft was then anastomosed to the target coronary vessel. The procedure was complete without major technical difficulties in all 3 patients.
No perioperative complications occurred. The postoperative course was uneventful without deaths and neurological events. The mean in-hospital stay was 10 ± 2 days. At follow-up, no residual myocardial ischemia was identified by ergometric and nuclear stress testing in all 3 patients.
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Comment
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Porcelain aorta still remains a challenge for the cardiac surgeon as it increases the risk of atheromatous embolism during manipulation. The reliable strategy potentially able to eliminate the risk of embolism induced by aortic manipulation is the avoidance of cardiopulmonary bypass and aortic cross-clamping. This approach can include complete arterial revascularization with in situ grafts, left internal thoracic artery grafts associated to multiple arterial grafting in a "T" or "Y" configuration and extra-anatomical bypass conduits to avoid proximal anastomoses on the ascending aorta.
Several arteries have been reported as the inflow site for extra-anatomical coronary artery bypass grafting [2–5]. In these 3 patients, we believed it was unsafe to use "T" or "Y" grafts on the left internal thoracic artery graft, as its small diameter was unfit for GSV diameter. All inflow sites except the carotid arteries had atheromatous disease. The GSV proximal anastomoses to the right common carotid artery were already described in off-pump coronary artery bypass grafting performed with the no-touch aorta approach [5], but this approach needs an additional incision and graft tunnelling into the chest and has an increased risk of graft kinking or twisting.
The LCCA as an inflow site has not been as extensively reported. The LCCA does not need an additional neck incision, and the surgical field is limited to the chest. However, surgical exposition of the LCCA is generally more difficult and its partial clamping can lead to a suboptimal cerebral perfusion, as its diameter is smaller than the innominate artery. On these bases, we believe that the use of the LCCA as an inflow site should be reserved to selected patients with severe atherosclerotic disease localized to the ascending aorta and innominate artery in which partial clamping does not alter cerebral perfusion.
In our limited experience, off-pump coronary artery bypass grafting with the LCCA as an arterial inflow is a safe and reliable technique to reduce the risk of atheromatous embolism in selected patients with porcelain aorta.
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References
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- Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgeryMulticenter Study of Perioperative Ischemia Research Group and the Ischemia Research and Education Foundation Investigators. N Engl J Med 1996;335:1857-1863.[Abstract/Free Full Text]
- Demirsoy E, Unal M, Arbatli H, Yagan N, Tukenmez F, Sonmez B. Extra-anatomic coronary artery bypass graftings in patients with porcelain aorta J Cardiovasc Surg 2004;45:111-115.[Medline]
- Bonatti J, Hangler H, Oturanlar D, et al. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting Eur J Cardiothorac Surg 1999;16(Suppl 2):S18-S23.[Abstract/Free Full Text]
- Suma H. Innominate and subclavian arteries as an inflow of free arterial graft Ann Thorac Surg 1996;62:1865-1866.[Abstract/Free Full Text]
- Bittner HB, Savitt MA. Management of porcelain aorta and calcified great vessels in coronary artery bypass grafting with off-pump and no-touch technology Ann Thorac Surg 2001;72:1378-1380.[Abstract/Free Full Text]
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Abstract
Introduction
