Brief
Communication
Coronary–Coronary
Bypass
Using Vein Graft on a Beating
Heart in a Patient with Porcelain Aorta
Nevzat Erdil, MD
Sanser Ates, MD
Ufuk Demirkilic, MD
Harun Tatar, MD
Cemal Sag, MD
There is increased risk of systemic embolism during cardiopulmonary bypass in patients with a severely atherosclerotic ascending aorta. We report a coronary–coronary
bypass in a 74-year-old man with a porcelain aorta. He underwent a proximal right coronary–distal right coronary artery bypass with a saphenous vein graft, combined with a
pedicled arterial graft (left internal mammary artery) to the left anterior descending
artery, in the presence of a beating heart without cardiopulmonary bypass. The patient
survived without evidence of perioperative myocardial infarction or cerebrovascular accident. One year later, follow-up angiography showed graft patency with good distal runoff. Coronary–coronary bypass on a beating heart without cardiopulmonary bypass can
be performed safely in a patient with porcelain aorta. (Tex Heart Inst J 2002;29:54-5)
S
evere atherosclerosis of the ascending aorta is associated with increased
morbidity and mortality during coronary artery bypass grafting (CABG)
because of the increased risk of perioperative atheroembolism.1-3 Moderate or severe atherosclerosis of the ascending aorta is present in as many as 13% of
the patients undergoing CABG.4 If atherosclerosis of the ascending aorta is severe,
standard coronary bypass surgery should not be used. We present a case in which
a patient with coronary artery disease and porcelain aorta underwent coronary–
coronary bypass grafting on a beating heart without cardiopulmonary bypass
(CPB), in order to avoid manipulation of the heavily calcified ascending aorta.
Case Report
Key words: Aortic
diseases/complications;
atherosclerosis; calcinosis/
complications; cerebrovascular disorders/prevention
& control; coronary artery
bypass/methods; embolism/
prevention & control
From: Department of
Cardiovascular Surgery
(Drs. Ates, Demirkilic, Erdil,
and Tatar) and Cardiology
(Dr. Sag), Alkan Hospital,
Ankara – Turkey
Address for reprints:
Nevzat Erdil, MD,
School of Medicine,
Inonu University;
and Department of
Cardiovascular Surgery,
Turgut Ozal Medical Center,
44069 Malatya – Turkey
© 2002 by the Texas Heart ®
Institute, Houston
54
In February 2000, a 74-year-old man was admitted to our hospital’s cardiovascular
clinic with unstable angina. After coronary angiography was performed, lesions
were detected in the proximal left anterior descending coronary artery (LAD) and
in the mid right coronary artery (RCA). Elective coronary artery bypass grafting
was planned.
Left internal mammary artery (LIMA) and saphenous vein grafts were prepared.
As we approached cannulation, we discovered that we could not place an aortic
cannula because the ascending aorta was completely atherosclerotic. We decided to
perform the operation in the presence of a beating heart, to avoid the complications of cardiopulmonary bypass. Because the RCA lesion was in the middle of the
vessel and solitary, we decided that proximal-to-distal right coronary bypass grafting would be feasible for a beating-heart procedure. Distal anastomosis of the
saphenous vein graft to the RCA was performed with the aid of 1 epicardial traction suture placed on the margin of the RCA and the other placed deeply on the
proximal segment of the RCA, in order to immobilize the artery and expose a good
anastomotic site. After the distal anastomosis was complete, we performed the
proximal anastomosis to the RCA in the atrioventricular groove, with the help of
Silastic bands (Fig. 1). We then performed a LIMA–LAD anastomosis.
After the operation, the patient had no need of inotropic or intra-aortic balloon
pump support. During his 20-hour stay in the intensive care unit, he showed no
electrocardiographic changes or enzyme elevation. There was no evidence of cerebrovascular accident during the postoperative period, and he was discharged from
the hospital on the 6th postoperative day on nothing but aspirin therapy (300
mg/day). When follow-up coronary angiography was performed 1 year later, both
the RCA and LAD anastomoses were patent.
Coronary–Coronary Bypass and Porcelain Aorta
Volume 29, Number 1, 2002
Discussion
Stroke is one of the major causes of morbidity following cardiac surgery, especially in patients with atherosclerotic ascending aorta.1 Although severe aortic
atherosclerosis and calcific degeneration of the aorta
are encountered occasionally in younger patients, this
condition is of course found most often in elderly patients; and a third of patients undergoing CABG in
recent years have been age 70 or older, according to
the national database maintained by the Society of
Thoracic Surgeons.5
There are different methods of avoiding manipulation of a heavily calcified ascending aorta and aortic
arch (porcelain aorta). These methods can be summarized as axillary or femoral cannulation with induction of cardiac fibrillation and avoidance of aortic
clamping; use of anastomotic sites other than the calcified ascending aorta; aortic arch reconstruction;
beating heart bypass without cardiopulmonary bypass; or a combination of these techniques. In addition to these methods, coronary–coronary bypass is
an alternative technique that may be used to bypass
isolated atherosclerotic coronary lesions, when the patient has a porcelain aorta.6
Coronary–coronary bypass can be performed either
between 2 segments of the same coronary artery, as in
our case, or from 1 branch of a coronary artery to an-
other (usually involving the right coronary tree). The
coronary–coronary bypass method, either with saphenous vein grafts or free arterial grafts, should be considered a workable option for off-pump coronary
artery bypass grafting when the aortic “no-touch”
technique is called for and other indications are in
place.
A surgeon who encounters a porcelain aorta at operation must quickly choose a safe and suitable revascularization method. The coronary–coronary bypass
technique, with beating heart, should be borne in
mind.
References
1.
2.
3.
4.
5.
6.
Leyh RG, Bartels C, Notzold A, Sievers HH. Management
of porcelain aorta during coronary artery bypass grafting.
Ann Thorac Surg 1999;67:986-8.
Mickleborough LL, Walker PM, Takagi Y, Ohashi M,
Ivanov J, Tamariz M. Risk factors for stroke in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;112:1250-8.
Kalimi R, Graver LM, Palazzo RS. A novel approach to
coronary revascularization in patients with severely diseased
aorta. Tex Heart Inst J 2000;27:106-9.
Wareing TH, Davilla-Roman VG, Barzilai B, Murphy SF,
Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy
for detection and treatment. J Thorac Cardiovasc Surg
1992; 103:453-62.
Ricci M, Karamanoukian HL, D’Ancona G, Bergsland J,
Salerno TA. Coronary artery bypass grafting in the presence of atheromatous or calcified aorta: on-pump or offpump? Heart Surg Forum 2000;3:12-4.
Nottin R, Grinda JM, Anidjar S, Folliguet T, Detroux
M. Coronary-coronary bypass graft: an arterial conduitsparing procedure. J Thorac Cardiovasc Surg 1996;112:
1223-30.
Fig. 1 Coronary–coronary bypass with saphenous vein graft
for right coronary artery lesion in a patient with porcelain
aorta.
Texas Heart Institute Journal
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