CABG in Coronary Artery Disease concomitant with Porcelain Aorta
Aliasghar Moeinipour, MD.; et al.
Coronary Artery Bypass Surgery in Coronary Artery Disease Concomitant with Porcelain Aorta: Great Challenge for Cardiac surgeon Aliasghar Moeinipour, Ahmad Amouzeshi, *Hamid Hoseinikhah Abstract A severe aortic calcification (porcelain aorta) carries a high risk of atheroembolism and bleeding during cardiac surgery, with an incidence range of 14% to 29%. Proximal anastomosis of conduits to the ascending aorta in patients undergoing coronary artery bypass grafting may be hazardous or impossible in the presence of complex aortic pathology. Various techniques have been introduced in order to avoid cannulation and clamping of the aorta. Herein, we present a technique in a high-risk group of such patients (Iranian Heart Journal 2014; 15 (1): 29-31).. Corresponding author : Hamid Hoseinikhah Department Cardiovascular surgery of Imam Reza Hospital: Mashhad University of Medical Sciences Email:
[email protected] Tel: 09153046163
he risk of atheroembolism in severe aortic atherosclerosis due to cannulation and clamping is well documented, although the incidence of cerebral and other systemic distal embolization has clearly increased in patients.[1]. Bleeding and rupture of calcific aortic walls are other life-threatening complications of this pathology that are hazardous and life-threatening complications with high rates of morbidity and mortality. Graft attachment may be technically difficult and associated with various complications such as increased incidence of anastomotic stenoses or occlusion and difficult technique for especially the proximal anastomosis of conduit to diseased aorta. In Lecture, we see many different options for the relief of this potential difficulty and complications such as the use of bilateral internal mammary artery, surgery on beating heart with or without cardiopulmonary bypass to avoid aortic cannulation, initiating cardiopulmonary bypass with peripheral cannulation, use of cardiopulmonary bypass with the fibrillatory method to avoid aortic clamping, and use of
total circulatory arrest to avoid aortic manipulation. [2–5]. In the current study, we report a technique for the treatment of patients with severe atherosclerosis of the aorta.
T
Case Report: A 50-year-old man was admitted to the department of cardiovascular surgery for coronary artery bypass grafting (CABG) surgery. The patient’s history revealed chronic obstructive pulmonary disease and a history of heavy smoking. In angiography and chest X-ray, a severely calcified ascending aorta was observed (Fig. 1, 2). Hence, on-pump beating heart CABG was planned by femoral artery cannulation and venous cannulation of the innominate vein. The left and right internal thoracic arteries were harvested by the skeletonized technique; then, left internal thoracic artery to left anterior descending artery, distal anastomosis of two reversed segments of the saphenous vein to the obtuse marginal (OM) branch of the circumflex coronary artery and the 29
CABG in Coronary Artery Disease concomitant with Porcelain Aorta
posterior descending arteries were constructed first. The proximal saphenous vein (OM) was sutured to the left internal thoracic artery in an end-to-side fashion, creating a “Y” graft with 7-0 Prolene. The other proximal saphenous, at the end of the posterior descending artery, was anastomosed to the right internal thoracic artery in an end-to-end fashion. The operation was completed without any complications.
Aliasghar Moeinipour, MD.; et al.
Discussion Atheromatous disease of the ascending aorta is a great challenge (with an incidence range of 14% to 29%) in patients undergoing cardiac operations [1,6]. Aortic cannulation and clamping may cause fatal strokes and troublesome bleeding by crushing the calcified aortic wall and dislodging the mobile atheroma into the systemic circulation. Various approaches have been described to avoid aortic manipulation to minimize the risk of atheroemboli. The classical no-touch technique relies on revascularization by using both internal thoracic arteries and composite grafts, or both and thoracic artery–saphenous veins under hypothermic ventricular fibrillation through aortic or peripheral cannulation without clamping. Extra-anatomic bypass, which means anastomosis between the graft and the truncal arteries, stands as a safe and reliable alternative. In literature, the axillary, innominate, right subclavian, and carotid arteries are noted as extra-anatomic proximal anastomotic sites [7, 8]. The prevalence of atherosclerotic plaques in the innominate artery varies between 21% and 30% in patients with severe atherosclerosis of the ascending aorta [9]. On the other hand, onpump beating heart CABG with artery composite in situ pedicle graft and RSVG (reversed saphenous vein grafts) is the best method of performing the surgery without touching the diseased aorta. Composite and sequential arterial and venous grafts ("y" graft) are the best and most effective approaches to avoiding aortic manipulation during CABG (10). Our technique does not necessitate low-flow cardiopulmonary bypass or circulatory arrest, which are other alternatives. In conclusion, by using this method, we avoid clamping and cannulation of the ascending aorta without further complications and this can be considered as an alternative approach in patients with unclampable aortas.
Figure 1: Porcelain aorta with heavy calcification in angiography
Figure 2: Porcelain aorta seen intraoperatively
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CABG in Coronary Artery Disease concomitant with Porcelain Aorta
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Aliasghar Moeinipour, MD.; et al.
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