Management of porcelain aorta during coronary artery bypass grafting

The Predictive Value of Aortic Calcification on Computed Tomography for Major Cardiovascular Events

As the prevalence of cardiovascular disease continues to increase, early identification of patients at high risk of major adverse cardiovascular events (MACE) using reliable diagnostic modalities is important. Transcatheter aortic valve implantation (TAVI) is a minimally invasive percutaneous procedure used to replace the aortic valve with a bioprosthetic one, often without the need for surgery. Extra coronary calcification in the ascending and/or descending thoracic aorta, aortic arch, and abdominal aorta has recently been identified as a method to quantify the extent of atherosclerotic cardiovascular disease. However, its definitive role in the prediction of MACE remains unclear. We performed a comprehensive review to summarize the current literature on the diagnostic and predictive value of thoracic and abdominal aortic calcification, as quantified in computed tomography, for the association, risk stratification, and prediction of MACE and after TAVI procedures. Despite increasing evidence, the predictive role of thoracic calcification still remains unproven, with a need for carefully tailored studies to confirm these findings.

Porcelain Aorta in a Young Person Living with HIV Who Presented with Angina

People living with human immunodeficiency virus have an increased cardiovascular risk due to higher prevalence of traditional risk factors, such as smoking, dyslipidemia, hypertension, diabetes, or obesity, and particular risk factors, such as inflammation, endothelial dysfunction, and antiretroviral therapy. Thus, people living with human immunodeficiency virus can develop accelerated atherosclerosis. The incidence of coronary artery disease in these patients may be twice as high compared with that of HIV-negative individuals with similar characteristics. "Porcelain aorta" is a term used to describe extensive circumferential calcification of the thoracic aorta. The pathophysiology of porcelain aorta is not fully understood. We present a case of a young man who was a smoker and living with HIV since childhood, without other traditional cardiovascular risk factors, who presented to the emergency room with a positive stress test for myocardial ischemia. Transthoracic echocardiography revealed normal regional and global myocardial wall motion, ascending aorta ectasia, and moderate aortic regurgitation. Coronary angiography showed a critical calcified proximal left anterior descending artery stenosis and an important calcification of the thoracic aorta. Therefore, the most important challenge was the management of coronary syndrome in a young person living with HIV, with associated porcelain aorta and aortic regurgitation.

Choosing Between Transcatheter Aortic Valve Replacement and Surgery in the Low-Risk Transcatheter Aortic Valve Replacement Era

The landmark results of the low surgical risk pivotal transcatheter aortic valve replacement (TAVR) trials fueled speculation that the role of surgical aortic valve replacement (SAVR) would be limited in the future. Instead, the field has pivoted away from reductive surgical risk stratification toward understanding the complex interplay of anatomy, timing, and surgical risk to optimize the lifetime management of aortic stenosis. In this review, we systematically explore the subtleties that influence the choice between TAVR and surgery in the low-risk TAVR era.

Surgical strategies for severely atherosclerotic (porcelain) aorta during coronary artery bypass grafting

Porcelain aorta (PA) is an asymptomatic atherosclerotic disease, characterized by circumferential calcification throughout the whole perimeter of the aorta. It is seen in 2% to 9.3% of patients undergoing elective coronary artery bypass grafting (CABG) and makes manipulation of the ascending aorta impossible. It has been clearly shown that most emboli seen and detected during the CABG procedure occur during aortic cross-clamping and aortic side-clamping. Manipulation of porcelain or a severely atherosclerotic aorta increases the risk of perioperative stroke. The incidence of stroke after CABG is between 0.48% and 2.9%, and the risk is correlated with the extent and severity of the atherosclerotic disease. A conventional CABG procedure involves successive steps that include cannulation of the ascending aorta, application of a cross-clamp to the aorta, and partial clamping of the aorta to create the proximal anastomosis. Therefore in procedures that involve cannulation, clamping, or proximal anastomosis, and where aortic manipulation is inevitable, preassessment of the atherosclerotic aortic plaques is crucial. Although many surgeons still rely on intraoperative manual aortic palpation, this approach has very low sensitivity and underestimates the severity of the atherosclerotic illness. Imaging methods including preoperative computed tomography or intraoperative epiaortic ultrasonography enable modification of the surgical technique according to the severity of atherosclerosis. Various surgical techniques have been described to reduce the risk of atheroembolism that may lead to cerebrovascular events in patients with severely atherosclerotic ascending aorta. Anaortic or "no-touch" techniques that do not utilize aortic manipulation may significantly decrease the development of neurological complications by avoiding aortic maneuvers known to cause emboli. In cases where severe atherosclerotic disease or other factors preclude safe use of the ascending aorta, modifications in the surgical techniques, such as switching to different cannulation sites including the axillary/subclavian, femoral and innominate arteries, or using hypothermic ventricular fibrillation and in-situ pedicled arterial grafts, or performing proximal anastomoses at alternative anatomical locations will enable CABG operations to be performed safely with low morbidity and mortality rates in patients with porcelain aortas.

Thoracic Aortic Calcification: Diagnostic, Prognostic, and Management Considerations

Thoracic aortic calcification (TAC) is associated with adverse cardiovascular outcomes, and for the cardiovascular imager, is predominantly encountered in 4 settings: 1) incidentally, for example, during a coronary artery calcium scan; 2) as part of dedicated screening; 3) in the evaluation of an embolic event; or 4) in procedural planning. This review focuses on TAC in these contexts. Within atherosclerosis, TAC is common, variable in extent, and begins in the intima with a patchy distribution. In metabolic disorders, aortitis, and radiation-associated cardiovascular disease, calcification preferentially involves the media and is often more concentric. As an incidental finding, atherosclerotic TAC provides limited incremental discriminative value, and current data do not support screening. After an embolic event, the demonstration of thoracic atheroma provides diagnostic clarity, but has limited treatment implications. Before any procedure, the plan often changes if the most severe form of TAC, a porcelain aorta, is discovered.

The π-Circuit Technique in Coronary Surgery: Analysis of 1359 Consecutive Cases

Coronary artery bypass surgery still has its unique role in the treatment of coronary artery disease. It faces, however, the continuous challenge of becoming even less invasive and more effective as cases become more complex. We here present the results of 1359 cases treated with the π-circuit technique which consists of an off-pump total myocardial revascularization using composite arterial grafts. The results demonstrate that it is a safe technique providing low mortality, stroke, renal failure, wound infection, and other complication rates. We suggest the application of this technique, as well as of other similar techniques regarding similar principles, especially in high-risk patients.

A practical and inexpensive proximal anastomosis technique in calcified aorta

Patients with severely calcified aorta have high risk of atheroemboli and bleeding during cardiac surgery. Clamping the ascending aorta to initiate cardiac arrest or to perform proximal anastomosis is a challenging problem. Beating heart coronary artery bypass grafting without aortic clamping is usually accepted as the best solution. Herein, we present a feasible and inexpensive proximal anastomosis technique without using aortic clamps for patients with severely atherosclerotic aorta.

Right Axillary Artery Cannulation in Aortic Valve Replacement

OBJECTIVE

This retrospective study aimed to evaluate the results of our experience with axillary artery cannulation via a side graft in aortic valve replacement in patients with ascending aortic atherosclerotic disease.

METHODS

From January 2002 to 2012, we operated on 76 patients for aortic valve disease with the use of the axillary artery for arterial inflow in our institute. The indications for cannulation of the axillary artery were aortic aneurysm in 37 patients, severe aortic atherosclerosis in 28 patients, and re do surgery in 11 patients.

RESULTS

Right axillary artery cannulation via a side graft provides sufficient antegrade aortic flow of 2.6 ± 0.1 L/m(2) during cardiopulmonary bypass. No additional arterial cannulation was necessary to obtain sufficient perfusion during cardiopulmonary bypass. Although permanent perioperative stroke was observed in two patients, this did not occur during the operation. There were no problems with cannulation or wound and graft infections. During the follow-up period, there were no thrombotic events due to an axillary graft stump in the right upper extremities.

CONCLUSIONS

Axillary artery cannulation via a side graft is a useful and safe option for cardiopulmonary bypass in patients with atherosclerotic disease of the ascending aorta undergoing aortic valve replacement.

Evaluation of coronary artery-saphenous vein composite grafts: the aortic no-touch technique

We retrospectively compared the results of conventional coronary artery bypass grafting (CABG) performed on patients who showed no preoperative evidence of serious atherosclerosis of the ascending aorta with the results of the aortic no-touch technique (using coronary artery-saphenous vein composite grafts) on CABG patients who did show such evidence. From 2003 through 2012, 3,152 consecutive patients underwent isolated primary CABG at our hospital. We chose 360 for the current study. The study group (n=120) comprised patients who had undergone operation via the aortic no-touch technique. Propensity-score-matching (1:2) was used to select the control group of 240 patients who had undergone conventional CABG. Early and late survival rates, reintervention-free survival rates, and freedom from cardiac death were compared. Early and late mortality rates were similar in the study and control groups (P=0.19 vs P=0.29, respectively), as were cardiac-related death (2.5% vs 2.1%, respectively; P=0.53) and overall death (8.3% vs 7.9%, respectively; P=0.51). Overall survival rates were 91.7% vs 92.1% and freedom-from-cardiac-death rates were 97.4% vs 97.5% (P=0.71 vs P=0.78, respectively; mean follow-up period, 5.27 ± 2.51 yr). Reintervention-free survival rates were also similar (96.7% vs 98.8%, respectively; P=0.2). As a result of the similar rates of early and late survival, reintervention-free survival, and freedom from cardiac death, we conclude that the aortic no-touch technique with composite grafts might be a reasonable option in patients who have atherosclerotic ascending aorta that cannot be clamped.

Innominate artery as an alternative site for proximal anastomoses in patients with a severely calcified aorta

BACKGROUND

Atheromatous plaques of the ascending aorta are one of the most important risk factors for postoperative mortality and morbidity in coronary artery bypass grafting (CABG). We have retrospectively analyzed the results of proximal anastomoses constructed on the innominate artery in patients with calcific atheromatous plaques (CAP) in their ascending aorta detected intraoperatively.

PATIENTS AND METHODS

This study is a retrospective review of 16 consecutive patients who underwent CABG operations and had CAP on their ascending aorta between November 2006 and June 2009. The atheromatous lesions were detected intraoperatively and the operation plan was changed to off-pump surgery. All the proximal anastomoses were made on the innominate artery, left internal thoracic artery (LITA) or the other saphenous vein grafts (SVG). Thirteen patients were male and three were female with a mean age of 63.7 ± 5.3 (ranged, 53-71) years.

RESULTS

A total of 56 distal anastomoses (3.5 per patient) and 25 proximal anastomoses on the innominate artery were performed. Of the 16 patients, seven (43.7%) had received a sequential SVG; two (12.5%) patients, sequential LITA graft; and one (6.25%) patient sequential SVG and LITA graft. One of the proximal anastomoses was performed on the SVG in four patients (25%) and on the LITA graft in one patient (6.2%). One patient (6.2%) died due to cerebrovascular morbidity. No other complications were observed.

CONCLUSIONS

The innominate artery is an alternative site for proximal anastomoses in patients with calcific atheromatous aorta.

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

Background

Cannulation, 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.

Methods

Between 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.

Results

Seven 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.

Conclusions

Innominate 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.

Pre- and perioperative risk factors predicting neurologic outcomes after coronary artery bypass surgery in patients with pre-existing neurologic events

BACKGROUND

A neurologic event (NE) after coronary artery bypass graft (CABG) surgery is a principal complication affecting morbidity and mortality. We investigated the risk factors predicting postoperative NEs and survival in patients with pre-existing NE undergoing CABG.

METHODS

Between 2001 and 2012, 3137 patients underwent isolated primary CABG. The data were stored in a computerized database and retrospectively evaluated. Patients were divided into 2 groups based on the existence of preoperative NE (study group; n=126) and without NE (n=3011). Uni- and multivariate logistic regression analyses were performed to evaluate the possible predictors of postoperative NEs. Survival was determined using Kaplan-Meier survival analyses of the study group and propensity score-matched control group.

RESULTS

The mean age of the 3137 patients was 60±9 years, and 28% (n=885) were female. Postoperative NE was seen in 4 (3.2%) patients with pre-existing NE and in 16 (0.5%) without pre-existing NE. Preoperative NE (odds ratio 4.47; 95% confidence interval 1.32-15.18; P=.01) and age (≥70 years; odds ratio 2.98; 95% confidence interval 1.21-7.33; P=.01) showed strong multivariate associations with postoperative NE. Median CHA2DS2-VASc scores were 4.5 (interquartile range 3-5) and 3 (range 0-4) in patients in the pre-existing and without NE groups, respectively (P=.01). The overall mean follow-up was 4.6±3 years. Overall survival rates (88.1% and 94%, respectively) were different between the 2 groups (P=.02).

CONCLUSIONS

Preoperative neurologic events and advanced age are significant risk factors predicting postoperative neurologic events. Meticulous management of the ascending aorta and carotid artery are important in diminishing postoperative neurologic events. A pre-existing neurologic event is also predictive for decreased overall survival.

An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem

Severe calcification of the ascending aorta (porcelain aorta) is a very difficult condition in cardiac surgery because of a high embolization potential during the process of cannulation, aortic cross-clamping and a particular difficulty to suture the proximal anastomosis. We described a case of a 68-year-old female referred to our Institute due to unstable angina. Further diagnostics revealed a severe high grade, multilevel fibrolipid symptomatic carotid stenosis and ostial left main coronary artery stenosis and a highly calcified ascending aorta and aortic arch. We performed simultaneous carotid segment replacement with the Dacron prosthesis and revascularisation of the left anterior descending coronary artery. Proximal venous anastomosis was created in the Dacron prosthesis of the right carotid artery. Perfusion of the patient was achieved via the graft sutured at the right subclavian artery due to impossibility of direct aortic cannulation.

Coronary-coronary bypass grafting to reduce the risk of aortic atheroembolism

Coronary-coronary bypass grafting refers to making anastomoses between two segments of the same coronary artery or between different coronary arteries, and provides less "touch" to the aorta, which is important for the patients with severely atherosclerotic ascending aorta. In this report we represent a case of a patient with extensive atherosclerotic aorta, in whom a saphenous vein graft was placed between the acute marginal and the posterior-descending branches of the right coronary artery during an off-pump coronary artery bypass grafting surgery.

Development of a Special Balloon Occlusion Device to Prevent Adverse Events in High-Risk Patients during Open Aortic Surgery

OBJECTIVE

To prevent clamp injury that may occur during aortic surgery, we aimed to develop a special balloon occlusion (BO) device to lower the thromboembolic risk in patients with severe atherosclerosis during aortic aneurysm repair.

METHODS

The study comprised two test phases: a laboratory-testing series focussing on flexible artificial aortas, and an experimental series conducted on 10 pigs.

RESULTS

The device proved to be effective during the laboratory tests and the experiments on pigs. No complications such as intraoperative balloon rupture, dislocation, or occlusion leaks occurred. No damage to the aortic vessels was observed in further histological examinations.

CONCLUSIONS

This BO device has the potential to become an alternative to cross-clamping for vascular surgeons in patients with severely atherosclerotic vessels.

A novel technique of coronary revascularization in porcelain aorta: report of two cases

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.

An Alternative Technique of Proximal Anastomosis in Patients with an Atherosclerotic Ascending Aorta

Coronary artery bypass grafting operations in patients with an atherosclerotic ascending aorta are still associated with an increased risk of cerebral embolism and mortality despite previously described techniques. Here we present an alternative technique for the construction of a proximal anastomosis avoiding aortic clamping and deep hypothermic circulatory arrest.

The use of the SonoSite ultrasound device for intraoperative evaluation of the aorta

OBJECTIVE

Neurologic complications remain a significant cause of morbidity and mortality in cardiac surgery. Risk factors for neurologic injuries include the presence of atheromatous disease in the aorta. Epiaortic ultrasound has been shown to be superior in detecting the extent and location of atheromatous disease. The SonoSite Corporation (Bothell, WA) has recently introduced an affordable, portable, high-resolution ultrasound device. This new device was compared with the Hewlett-Packard Sonos 5550 ultrasound device (currently manufactured by Philips, Andover, MA) to determine suitability for this purpose.

DESIGN

Prospective, serial comparison of 2 devices.

SETTING

University hospital.

PARTICIPANTS

Fifty consecutive cardiac surgery patients.

INTERVENTIONS

Intraoperative epiaortic ultrasound images were obtained using a SonoSite 180 Plus ultrasound device and a Hewlett-Packard Sonos 5500 ultrasound device. Three observers graded recorded images based on extent of atheromatous disease.

MEASUREMENTS AND MAIN RESULTS

Two patients were excluded because of errors in recording images. For the 48 remaining patients, consensus (median) grades had an observed agreement of 93.6% compared with a chance agreement of 67.7%. This correlates to a kappa value of 0.80 or near-excellent agreement.

CONCLUSIONS

The near-excellent agreement of the 2 devices is acceptable, thus providing a unique opportunity to expand the use of epiaortic ultrasound imaging.

[The calcified ascending aorta in aortocoronary bypass]

Heavily calcified ascending aorta significantly increased morbidity and lethality during open-heart surgery. Cannulation and clamping (partial or total) of severely atherosclerotic ascending aorta can easily cause damage and rupture of aortic wall, with consequential distal (often fatal) embolization with atheromatous debris (brain, myocardium). From June 1998. until June 2000, 11 of 2,136 (0.5%) patients who underwent coronary artery bypass grafting were with the severe atheromatous ascending aorta. The site of cannulation was in the aortic arch in three patients (aorta was occluded with Foley catheter in one case, and single clamp technique was used in the other two cases). The femoral artery was the cannulation site in other five cases. Profound hypothermia, ventricular fibrillation, and circulatory arrest, with no cross-clamping or cardioplegia, were used in three patients. Two patients were operated on with extracorporeal circulation, one in normothermia, on the beating heart, the other in moderate hypothermia, on fibrillating heart. In three patients myocardial revascularization was performed on the beating heart, in normothermia, without extracorporeal circulation. Postoperative course was uneventful in all 11 patients. Neither atheroembolism in the peripheral organs, nor atheroembolism of the extremities occurred. The proposed surgical approaches have the potential to reduce the prevalence of stroke and systemic embolization associated with coronary artery bypass grafting in patients with heavily calcified ascending aorta. This result was achieved due to the applied modifications of standard cardiosurgical technique.

The Use of an Aortic Connector System in a Patient with Severe Calcified Ascending Aorta

Patients with severe calcified ascending aorta ("porcelain aorta") present a surgical challenge. Off-pump coronary artery bypass grafting (OPCAB), using new automated proximal anastomotic devices, provide a surgical alternative for patients who are not candidates for in situ arterial grafting. We present a 74-year-old male with double-vessel disease and a large calcified aneurysm of the left anterior wall. Left ventricular function was poor with an ejection fraction of 24%. The beating heart technique was used for the distal anastomosis and ventriculoplasty. The proximal anastomosis was constructed with an automated aortic connector system, thereby avoiding clamping of the severely diseased aorta.

'No touch' techniques for porcelain ascending aorta: comparison between cardiopulmonary bypass with femoral artery cannulation and off-pump myocardial revascularization

BACKGROUND

Detection of severe atherosclerotic ascending aorta during coronary artery bypass grafting requires alterations in the standard surgical technique to reduce the probability of stroke-related atheroembolization. Off-pump coronary artery bypass grafting (OPCAB) confers the benefits of avoiding aortic cannulation and clamping, and may therefore attenuate this risk.

METHODS

OPCAB (n = 41) was compared to cardiopulmonary bypass (CPB) using femoral arterial cannulation and hypothermic fibrillatory arrest (n = 15), in patients with porcelain ascending aorta undergoing myocardial revascularization. In both groups, a 'no touch' technique was applied by avoiding aortic cannulation and clamping. Proximal anastomoses on the atherosclerotic aorta were avoided by arterial grafting, (in-situ or T-graft configurations) in all cases.

RESULTS

Operative mortality was comparable (2.4% and 6.6% in the OPCAB and CPB groups respectively, p = NS). The rate of adverse neurological events, (two strokes and one transient ischemic attack), was higher in the CPB group (p = 0.0164). Based on brain CT, the nature of the recorded stroke suggested retrograde emboli. Three year survival (Kaplan-Meier) for the OPCAB and CPB groups was 86.7% and 81.3%, respectively (p = NS). Occurrence of late neurological adverse events during follow-up (8-51 months) was similar.

CONCLUSIONS

In patients with porcelain ascending aorta undergoing myocardial revascularization, neurological outcome of OPCAB patients is better than CPB using femoral artery cannulation.

Coronary artery bypass grafting with left internal mammary artery and right gastroepiploic artery, with and without bypass

BACKGROUND

Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease.

METHODS

From January 1995 to July 2000, 171 consecutive patients were reviewed in a prospective database. Ninety-one patients underwent coronary artery bypass grafting without cardiopulmonary bypass (group A), and 80 patients were operated on under cardiopulmonary bypass with aortic cross-clamp and cardioplegia (group B).

RESULTS

Patient data were similar in both groups except for the Euroscore (mean; 3.4+/-6.1, group A versus 2.5+/-4.5, group B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection fraction (mean, 54.6%+/-15.8%, group A versus 63.1%+/-12.7%, group B; p < 0.001). Severe aortic calcification was present in 6 group A patients, versus no patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to cardiopulmonary bypass occurred in 1 patient, who was excluded from the study. Bleeding was higher in group A (852.6+/-288 mL versus 712.4+/-274 mL, p < 0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. Myocardial infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon pump was used in 2 patients (group B). One patient died (group A) and 1 had an embolic stroke (group B). After discharge, 2 more patients died (group A, day 91; group B day 141), and 1 patient suffered an embolic stroke (group B). One patient in each group presented with dysfunction of the gastroepiploic artery graft requiring successful percutaneous transluminal angioplasty on the right posterolateral artery.

CONCLUSIONS

These results suggest that off-pump coronary artery bypass grafting using the left internal thoracic artery and gastroepiploic artery is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta.

Management of porcelain aorta and calcified great vessels in coronary artery bypass grafting with off-pump and no-touch technology

A 69-year-old woman presented with postinfarct unstable angina and decreased ventricular function secondary to significant left main coronary artery stenosis in combination with total right coronary artery occlusion. We did successful off-pump coronary revascularization in this patient with severely calcified ascending aorta and great vessels, subtotal aortobiiliac stenoses, a history of previous stroke, and right carotid endarterectomy.

Double coronary endarterectomy on the beating heart in two patients with porcelain aorta

Patients with porcelain aorta carry a high risk of systemic embolism during coronary artery bypass grafting. Avoiding manipulation of the aorta during operation using the beating heart approach can prevent atheroemboli. In patients with diffuse atherosclerotic coronary artery disease who require endarterectomy, coronary bypass operations can be done safely on the beating heart.