01 сентября 2001 00:00
Management of porcelain aorta during coronary artery bypass grafting
Background . Patients with porcelain aorta carry a high risk of systemic embolism during coronary artery bypass grafting. No currently proposed surgical approach avoids manipulation of the heavily calcified ascending aorta. A novel surgical approach avoiding manipulation of the porcelain aorta was evaluated with regard to its efficacy in prevention of atheroemboli.
Methods . The following surgical protocol was performed in 23 patients with porcelain aorta: (1) arterial cannulation of the axillary artery, (2) hypothermic fibrillatory arrest for performance of the distal anastomosis, and (3) construction of the proximal anastomosis to the inominate artery
Results . The postoperative course was uneventful in all patients. No patient experienced a cerebrovascular accident or visceral organ injury as a result of atheroemboli.
Conclusions . The proposed surgical approach is safe and reliable in patients with porcelain aorta and has the potential to reduce the prevalence of stroke and systemic embolization associated with coronary artery bypass grafting in patients with porcelain aorta.
Severe atherosclerosis of the ascending aorta is associated with increased morbidity and mortality during coronary artery bypass grafting because of the increased risk of perioperative atheroembolism    . The incidence of significant atheromatous disease of the ascending aorta in patients undergoing cardiac operation varies between 14% and 29% in recent series   . At autopsy Blauth and coworkers  identified a strong correlation between atheroembolism and ascending aortic atherosclerosis in 221 patients who died after cardiac operation. Most of these patients (46 [96%] of 48) with evidence of atheroemboli had severe atherosclerosis of the ascending aorta  .
At least three different maneuvers during coronary artery bypass grafting can cause atheromatous embolism from the diseased ascending aorta: (1) cannulation of the aorta,
A surgical protocol avoiding manipulation of a heavily calcified ascending aorta and aortic arch (porcelain aorta) was evaluated with regard to its efficacy in preventing atheroembolism. The protocol consisted of a combination of three techniques: (1) arterial cannulation of the axillary artery; (2) hypothermic fibrillatory arrest for performing the distal anastomosis; and (3) construction of the proximal anastomosis to the inominate artery before the start of cardiopulmonary bypass
Patients and methods
Analysis of 1,861 consecutive patients undergoing
Cardiopulmonary bypass was conducted either at moderate hypothermia with a core temperature of 28°C or at deep hypothermia with circulatory arrest at 20°C when needed. A nonpulsatile pump flow was maintained at 2.4
The axillary artery was exposed through an incision below and parallel to the right clavicle after one or both IMAs were harvested. A transverse incision was made, and the axillary artery was cannulated
Surgical data of the 23 patients are presented in . [Table 2] Axillary artery cannulation was uncomplicated in all patients, and cardiopulmonary bypass flow with 2.4
One patient had transient mild weakness and numbness of the right arm caused by brachial plexus alteration. No new major adverse cerebral complications, defined as stroke, transient ischemic attack, stupor, or coma, at time of hospital discharge were observed. Two patients had short episodes of confusion that were fully resolved at the time of discharge. No patient had evidence of visceral organ injury as a result of an atheroembolic event detected by clinical and laboratory findings. Furthermore, no evidence of atheroembolism of the extremities could be detected.
The significance of atheroemboli from severe atherosclerosis of the ascending aorta was highlighted by Mills and Everson  , who described an extraordinarily high incidence of stroke after cannulation and clamping of a severe atherosclerotic ascending aorta, with nine (45% [9 of 20]) cerebrovascular accidents and four fatal strokes in a series of 20 patients  .
On the basis of these findings, modifications of standard surgical techniques are mandatory in patients with severe atherosclerosis of the ascending aorta to avoid atheroemblism. In most proposed surgical modifications of the standard technique, the cannulation side is either the aortic arch or the femoral arteries        . However, coexisting aortic arch atherosclerosis is a problem, and cannulation of the aortic arch may result in atheroembolism   . Culliford and coworkers  reported liberation of debris in 2 of 12 patients with severe atherosclerosis of the ascending aorta after cannulation of the distal ascending aorta or the aortic arch in an area thought to be free of atherosclerotic changes by palpation and observation. Therefore we believe that neither the ascending aorta nor the aortic arch should be touched if at all possible in patients with atherosclerosis of the ascending aorta. The high incidence of abdominal aortic and iliofemoral artery disease in patients with coronary artery disease can result in inability to cannulate the femoral arteries   . Furthermore, retrograde blood flow through a diseased aorta carries a high risk of retrograde atheroemboli   . An alternative site for arterial cannulation that avoids manipulation of the ascending aorta or aortic arch and provides antegrade blood flow is the axillary artery. Sabik and colleagues  demonstrated that axillary artery cannulation is an effective and safe technique of arterial cannulation for cardiopulmonary bypass in patients with severe atherosclerosis of the ascending aorta (n = 16).
In addition to arterial cannulation, clamping and declamping of a diseased aorta invites the risk of atheroemboli. Hypothermic circulatory arrest with endarterectomy, patch aortoplasty, or graft replacement of the ascending aorta may be an acceptable practice    . However, these demanding surgical modifications expose the patient to an extended surgical procedure with an overall increased perioperative risk. Proximal SV anastomoses
The present study focused on the severely calcified ascending aorta, which is easily diagnosed by palpation or chest
Although patients with porcelain aorta carry a high risk for atheroemboli, none of our patients had any clinical evidence of major adverse cerebral complications or visceral organ injury. We believe this result to be due to the modification in surgical management, which avoids manipulation of the ascending aorta. The simplicity and applicability of the technique presented, as well as the clinical results, are encouraging and justify this combined approach and should be added to the surgeon's armamentarium. However, prospective, randomized studies will be necessary to determine the best way to manage the diseased aorta during coronary artery bypass grafting.
1.Roach G.W., Kanchuger M., Mangona C.M.. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med 1996;335:1857−1863.
2.Mickleborough L.L., Walker P.M., Takagi Y., Ohashi M., Ivanov J., Tamariz M.. Risk factors for stroke in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;112:1250−1259.
6.Blauth C.I., Cosgrove D.M., Webb B.W.. Atheroembolism from the ascending aorta. J Thorac Cardiovasc Surg 1992;103:1104−1112.
7.Aranki S.F., Rizzo R.J., Adams D.H..
8.Weinstein G., Killen D.A.. Innominate artery coronary artery bypass graft in a patient with calcific aortitis. J Thorac Cardiovasc Surg 1980;79:312−313.
9.Mills N.L., Everson C.T.. Atherosclerosis of the ascending aorta and coronary artery bypass. J Thorac Cardiovasc Surg 1991;102:546−553.
10.Akins C.. Noncardioplegic myocardial preservation for coronary revascularization. J Thorac Cardiovasc Surg 1984;88:174−181.
11.Culliford A.T., Colvin S.B., Rohrer K., Baumann F.G., Spencer F.C.. The atherosclerotic ascending aorta and transverse arch. Ann Thorac Surg 1986;41:27−35.
12.Ott D.A., Cooley D.A.. The difficult proximal coronary anastomosis. Bull Tex Heart Inst 1979;6:55−58.
13.Sabik J.F., Lytle B.W., McCarthy P.M., Cosgrove D.M.. Axillary artery. J Thorac Cardiovasc Surg 1995;109:885−891.
14.Ribakove G.H., Katz E.S., Galloway A.C.. Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch. Ann Thorac Surg 1992;53:758−763.
15.Price D.L., Harris J.. Cholesterol emboli in cerebral arteries as a complication of retrograde aortic perfusion during cardiac surgery. Neurology 1970;20:1209−1214.
16.Martin W.R.W., Hashimoto S.A.. Stroke in coronary bypass surgery. Can J Neurol Sci 1982;9:21−26.
17.Marshall W.G., Barzilai B., Kouchoukos N.T., Saffitz J.. Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg 1989;48:339−344.
18.Tobler H.G., Edwards J.E.. Frequency and location of atherosclerotic plaques in the ascending aorta. J Thorac Cardiovasc Surg 1988;96:304−306.
01 сентября 2001 | 00:09Reversed-J inferior sternotomy for beating heart coronary surgery
Reversed-J inferior sternotomy for beating heart coronary surgery
01 сентября 2001 | 00:09Outcome of coronary endarterectomy: a case-control study
Outcome of coronary endarterectomy: a case-control study
01 сентября 2001 | 00:09Хирургическая анатомия сердца
Хирургическая анатомия сердца
01 сентября 2001 | 00:09Реплантация конечностей
01 сентября 2001 | 00:09Реплантация пальцев