Extraanatomical coronary artery bypass grafting in patients with severely atherosclerotic (Porcelain) aorta

Abstract

BackgroundCannulation, cross clamping, or partial clamping of the aorta during a proximal anastomosis may cause embolic complications in patients with severely atherosclerotic (porcelain) aortas. These patients carry high morbidity and mortality risks due to intraoperative atheroembolism.MethodsBetween June 2008 and May 2010, 972 open heart surgery operations were performed in our department. In this group there were 41 patients who had severe atherosclerotic plaques in the aorta (porcelain aorta), and 9 of these underwent an extraanatomical coronary artery bypass grafting (CABG). These 9 patients were retrospectively analyzed and their demographic data, patient risk factors, and preferred surgical methods were reviewed.ResultsSeven patients underwent two-vessel CABG, while 2 underwent three-vessel CABG. Off-pump surgery was performed for 7 patients. CABG was performed with beating heart technique under cardiopulmonary bypass via femoral artery and right atrial cannulation without cross clamping in 2 of the patients. Postoperative course was uneventful in all patients. Mean length of stay in the intensive care unit was 2.11 ± 0.78 days. Mean hospitalization was 7.22 ± 0.97 days. Mean follow-up was 11.33 ± 3.67 months, and no cerebrovascular events were observed during this period. Postoperative evaluation of the grafts by multislice computed tomography revealed sufficient patency in all patients.ConclusionsInnominate artery is an alternative inflow source for the untouchable ascending aorta caused by severe atherosclerotic disease (porcelain aorta). In this group of patients, the risk of systemic embolisation and perioperative neurologic complications can be minimized by avoiding manipulation of the ascending aorta and using the innominate artery.

Porcelain Aorta

“…29,30,60 Hunold et al 64 found severe calcification of the thoracic aorta in 13 of 1812 patients (0.7%) with known or suspected CAD who underwent an EBCT scan. The prevalence of PA was found to be 7.5% in patients evaluated for AS, 7 between 1.2% and 13.6% in patients undergoing valvular or coronary revascularization surgeries, 8,14,[65][66][67][68] and between 5% and 33% in the patients undergoing TAVR.…”

“…Alternatively, if the aorta is not totally calcified and a noncalcified area is ascertained by epiaortic scanning and palpation, a "clampless" proximal anastomosis can be performed using a Heartstring device. 8,59,68 Lev-Ran et al 59 retrospectively compared the results of coronary revascularization between cardiopulmonary bypass with femoral artery cannulation in 15 patients and off-pump CABG in 41 patients with PA. There was only 1 case of perioperative mortality (2.4%) and there were no cases of perioperative stroke or transient ischemic attack in the off-pump CABG group.…”

“…The cardiopulmonary bypass group had 1 mortality (6.6%), 3 perioperative strokes or transient ischemic attacks (20%), and a lower rate of incomplete revascularization (6.6%). Other options include femoral or axillary artery cannulation for cardiopulmonary bypass, 68,83 intraluminal balloon catheter as a substitute for external clamps, 84 avoidance of proximal graft anastomoses on the ascending aorta, 85 and CABG performed during deep hypothermic circulatory arrest. 86 Extended procedures such as ascending aorta endarterectomy, 87 patch aortoplasty, and graft replacement of the ascending aorta 88,89 have also been described.…”

Porcelain Aorta in a Patient Undergoing Coronary Artery Bypass Grafting Surgery

“…2 Furthermore, coronary artery bypass on a beating heart (off-pump surgery) can be performed safely in patients with a severely calcified (porcelain) ascending aorta, 3 in addition to the use of ITA grafts associated with the no-touch aorta technique and placing proximal anastomoses on the ITA, which are useful strategies to reduce the perioperative risk of cerebrovascular events due to atheroembolism. 4 Unilateral Dilated Fixed Pupil After Thoracic Surgery: Need for Concern?…”

“…Pilocarpine will constrict the pupil in nonpharmacologic etiologies but there will be no response if the mydriasis is due to a pharmacologic agent. 1,4,5 Pupillary dilation not resolving even after 48 hours of discontinuation of the drugs also may suggest the requirement…”