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Coronary surgery in patients with porcelain aorta
Miguel Sousa Uva1, Albino Pedro, Rui Caria
1Hospital da Cruz Vermelha Portuguesa, Lisboa. uvamiguel@hotmail.com
Insights
A novel no-touch surgical technique successfully revascularized patients with porcelain ascending aorta undergoing coronary artery bypass grafting. This approach avoided aortic cannulation, ensuring safe outcomes without mortality or neurologic complications.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Vascular Surgery
Background:
- Coronary artery bypass grafting (CABG) is a standard treatment for complex coronary artery disease.
- Porcelain ascending aorta, characterized by extensive calcification, poses significant challenges during conventional CABG, often precluding standard aortic cannulation and clamping.
- This condition necessitates alternative surgical strategies to ensure patient safety and procedural success.
Observation:
- Four patients with unstable angina and left main or three-vessel disease presented with intra-operative findings of porcelain ascending aorta.
- The severe calcification of the ascending aorta prevented standard cardiopulmonary bypass cannulation and aortic cross-clamping.
- A modified 'no-touch' operative technique was employed to address this anatomical challenge.
Findings:
- The no-touch technique utilized bilateral internal mammary arteries in three patients, with supplementary Y-grafting as needed.
- Three patients underwent successful off-pump myocardial revascularization.
- The fourth patient received pump-assisted beating heart surgery with an automatic connector for proximal saphenous graft anastomosis.
- All procedures were completed without operative mortality or new neurologic morbidity.
- Patients were discharged by post-operative day 8, indicating a favorable recovery profile.
Implications:
- The no-touch operative technique offers a viable and safe alternative for coronary artery bypass grafting in patients with porcelain ascending aorta.
- This strategy effectively mitigates the risks associated with aortic manipulation in severely calcified aortas.
- Successful implementation demonstrates the adaptability of cardiac surgical techniques to complex patient anatomies, improving revascularization options.
Abstract:
Four patients with unstable angina due to left main or three-vessel disease scheduled for coronary artery bypass grafting were found intra-operatively to have porcelain ascending aorta, defined as massive calcification of the ascending aorta from the aortic valve to the transverse arch, precluding ascending aorta cannulation or clamping. A no-touch operative technique was applied using the two internal mammary arteries in three cases, with complementary Y-grafting when necessary. Three cases underwent off-pump myocardial revascularization. The fourth case was revascularized with pump-assisted beating heart and proximal saphenous graft anastomosis with an automatic connector. There was no mortality or neurologic morbidity and all patients were discharged home before post-operative day 8.