Use of Composite Graft in Patients with Coronary Artery Diseases Concomitant with Porcelain Aorta: A Safe Technique and case series in Severe Aortic Calcification

Document Type : Original Article

Authors

1 Associate Professor of Cardiac Surgery, Department of Cardiac Surgery, Emam Reza hospital, Mashhad University of Medical Science, Mashhad, Iran

2 Assistant Professor of Cardiac Surgery, Department of Cardiac Surgery, Emam Reza hospital, Mashhad University of Medical Science, Mashhad, Iran

3 Department of Medical Sciences, Mashhad Branch, Islamic Azad University, Mashhad, Iran

4 Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran

5 lung Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

Abstract

Background: Surgery in patients with severe calcification of the aorta, also known as “porcelain aorta”, is challenging for cardiac surgeons. In this study, we evaluated the efficacy of composite grafts in avoidance of aortic manipulation among patients with porcelain aorta undergoing coronary artery bypass grafting (CABG).

Objectives: The aim of current study was to investigate of use of composite graft in patients with coronary artery diseases concomitant with porclain aorta.

Methods: Ten patients among admitted ones for CABG over 3 years showed severe calcification of the aorta. We used a composite graft for revascularization of the target vessel without manipulation of the aorta. In patients with CAD and porcelain aorta, off-pump CABG was applied to avoid cannulation of the aorta. Moreover, a composite graft was used for internal mammary artery (unilateral/bilateral) to avoid partial clamping of the aorta.
 
Results: Among ten patients with the mean age of 72.5 years seven patients were male and 3 were female. The most common risk factors were diabetes (6 patients), hypertension (5 patients), smoking (5 patients), and hyperlipidemia. Four patients had thetwo-vessel disease, while the remaining had thesix-vessel disease. In the intraoperative and postoperative periods, no hemodynamic instability was reported in any of the patients. Similarly, no ischemic complications due to femoral artery cannulation (lower limb ischemia) were reported. Based on the findings, no neurologic complications occurred in the early postoperative period and 12-month follow-up (causing no neurologic deficits). Postoperative evaluation of the grafts via computed tomography showed sufficient patency in all patients.

Conclusion: Coronary artery disease, concomitant with severe calcification of the aorta, is a challenging condition for cardiac surgeons, given the higher risk of atheroembolic events and serious morbidity. Although multiple techniques have been described for avoiding manipulation of the aorta in these patients, the composite graft technique may be a simple and safe procedure with reduced risk of cerebrovascular events due to atheroembolism.

Keywords

Open Access Policy: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/

References

1. Demirsoy E, Unal M, Arbatli H, Yagan N, Tukenmez F, Sonmez B. Extra-anatomic coronary artery bypass graftings in patients with porcelain aorta. J Cardiovasc Surg. 2004;45(2):111.[PubMed:15179344].
 
2. Roach GW, Kanchuger M, Mangano CM, Newman M, Nussmeier N, Wolman R,et al. Adverse cerebral outcomes after coronary bypass surgery.Multicenter study of perioperative ischemia research group and the ischemia research and education foundation investigators. N Engl J Med. 1996;335(25):1857-63. doi:10.1056/NEJM199612193352501. [PubMed:8948560].
https://doi.org/10.1056/NEJM199612193352501
PMid:8948560
 
3. Moeinipour A, Amouzeshi A, Hoseinikhah H. Coronary artery bypass surgery in coronary artery disease concomitant with porcelain aorta: great challenge for cardiac surgeon. Iran Heart J. 2014;15(1):29-31.
 
4. Sirin G,Sarkislali K,Konakci M,Demirsoy E. Extraanatomical coronary artery bypass grafting in patients with severely atherosclerotic (Porcelain) aorta. J Cardiothorac Surg. 2013;8:86.
https://doi.org/10.1186/1749-8090-8-86
PMid:23587129 PMCid:PMC3639065
 
5. Leyh RG, Bartels C, Nötzold A, Sievers HH. Management of porcelain aorta during coronary artery bypass grafting. AnnThorac Surg. 1999;67(4):986-8.
https://doi.org/10.1016/S0003-4975(98)01370-8
PMid:10320239
 
6. SadeghpourTabaee A, Rostami A, Soheila A, Khamoushi A. Coronary artery bypass graft in porcelain aorta. Int Cardivasc Res J. 2008;1(4):245-8.
 
7. Tamura K, Nomura F, Mukai S, Yoshitatsu M, Sakao J, Ihara K. Combined aortic valve replacement and coronary artery bypass grafting with in situ arterial grafts for porcelain aorta. Ann Thorac Cardiovasc Surg. 2003;9(3):206-
 
8. [PubMed: 12875646]. 8. Bittner HB, Savitt MA. Management of porcelain aorta and calcified great vessels in coronary artery bypass grafting with off-pump and no-touch technology. Ann Thorac Surg. 2001;72(4):1378-80.
https://doi.org/10.1016/S0003-4975(01)02568-1
PMid:11603471
 
9. Yamaguchi A, Adachi H, Tanaka M, Ino T. Efficacy of intraoperative epiaortic ultrasound scanning for preventing stroke after coronary artery bypass surgery. Ann Thorac Cardiovasc Surg. 2009;15(2):98-104. [PubMed:19471223].
 
10. Davila-Roman VG, Barzilai B, Wareing TH, Murphy SF, Kouchoukos NT. Intraoperative ultrasonographic evaluation of the ascending aorta in 100 consecutive patients undergoing cardiac surgery. Circulation. 1991;84(5 Suppl):III47-53. [PubMed:1934441].
 
11. Lev‐Ran O, Ben‐Gal Y, Matsa M, Paz Y, Kramer A,Pevni D, et al. 'No touch'techniques for porcelain ascending aorta: comparison between cardiopulmonary bypass with femoral artery cannulation and off‐pump myocardial revascularization. J Card Surg. 2001;17(5):370-6. [PubMed:12630532].
https://doi.org/10.1111/j.1540-8191.2001.tb01161.x
PMid:12630532
 
12. Weinstein G, Killen D. Innominate artery-coronary artery bypass graft in a patient with calcific aortitis. J Thorac Cardiovasc Surg. 1980;79(2):312-3.[PubMed:6986005].
https://doi.org/10.1016/S0022-5223(19)37992-9
PMid:6986005
 
13. Matsuda N, Kamihira S, Kanaoka Y, Ishiguro S, Ohgi S. Off‐pump axillo‐coronary artery bypass grafting with porcelain aorta. J Card Surg. 2005;20(6):586-8.
https://doi.org/10.1111/j.1540-8191.2005.00125.x
PMid:16309420
 
14. Kovačević P, Velicki L, Redžek A, Golubović M, Till V, Ivanović V. An unusual origin of proximal coronary bypass anastomosis in a patient with porcelain aorta: how we solved the problem. Med Pregl. 2011;64(3-4):215-8.[PubMed:21905604].
https://doi.org/10.2298/MPNS1104215K
PMid:21905604
 
15. Akpinar B, Güden M, Sanisoğlu I, Konuralp C, Yilmaz O, Sönmez B. A no-touch technique for calcified ascending aorta during coronary artery surgery. Texas Heart Inst J. 1998;25(2):120-3. [PubMed:9654656].
 
16. Wu MY, Lin PJ, Haung YK, Tsai FC. A novel technique of coronary revascularization in porcelain aorta: report of two cases. Surg Today. 2008;38(2):157-60.
https://doi.org/10.1007/s00595-007-3579-4
PMid:18239876
 
17. Culliford AT, Colvin SB, Rohrer K, Baumann FG, Spencer FC. The atherosclerotic ascending aorta and transverse arch: a new technique to prevent cerebral injury during bypass: experience with 13 patients. Ann Thorac Surg. 1986;41(1):27- 35.
https://doi.org/10.1016/S0003-4975(10)64492-X
PMid:3942429
 
18. Kudo M, Misumi T, Koizumi K. Aortotomy and endarterectomy of the ascending aorta for aortic valve replacement in a patient with porcelain aorta. Surg Today. 2005;35(11):1000-3.
https://doi.org/10.1007/s00595-005-3058-8
PMid:16249862
Razavi International Journal of Medicine
Volume 6, Issue 4
October 2018
Pages 1-4

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