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Coronary bypass grafting with totally calcified or acutely dissected ascending aorta
P S Peigh1, V J DiSesa, J J Collins
1Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA 02115.
Insights
Internal mammary arteries serve as effective bypass conduits for patients with diseased aortas, offering a zero-mortality surgical option. This approach is crucial when the ascending aorta prevents standard coronary artery bypass grafting.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Ascending aortic disease, including calcification and dissection, poses challenges for standard coronary artery bypass grafting (CABG).
- Proximal anastomoses for CABG can be difficult or impossible in patients with severe aortic pathology.
- Alternative bypass strategies are needed for patients with extensively diseased aortas.
Purpose of the Study:
- To evaluate the safety and efficacy of using internal mammary arteries (IMAs) as proximal conduits in CABG patients with ascending aortic disease.
- To assess outcomes in patients requiring alternative bypass strategies due to aortic calcification or dissection.
- To determine the feasibility of IMA grafts when the aorta is unsuitable for standard proximal anastomoses.
Main Methods:
- Retrospective analysis of 10 patients with ascending aortic disease undergoing CABG between 1984 and 1988.
- Utilized single or bilateral internal mammary arteries as the primary inflow source.
- Employed profound hypothermia and circulatory arrest techniques in most cases, avoiding aortic cross-clamping.
- Saphenous vein grafts were used to connect IMAs to distal coronary vessels when necessary.
Main Results:
- Zero operative mortality was observed in the study cohort.
- One patient experienced a perioperative myocardial infarction, and another had a transient stroke.
- All patients demonstrated favorable outcomes during 1- to 6-year follow-up.
- Internal mammary arteries proved to be a viable alternative for proximal anastomoses in complex aortic cases.
Conclusions:
- Internal mammary arteries are a safe and effective option for CABG in patients with severely diseased ascending aortas.
- This technique provides a valuable alternative when aortic calcification or dissection precludes standard grafting procedures.
- The use of IMAs as proximal conduits supports excellent long-term patient outcomes.
Abstract:
From August 1984 through November 1988, 10 of 2,658 patients undergoing coronary artery bypass grafting had ascending aortic disease that was not amenable to proximal anastomoses for coronary bypass grafting. This was due to a calcified aorta in 6 and acute aortic dissection in 4. There were 5 male and 5 female patients with a mean age of 71 years. Cannulation site was the femoral artery in 5, ascending aorta in 3, and aortic arch in 2. Profound hypothermia and ventricular fibrillation, with no cross-clamp or cardioplegia, was used in 9 patients, and circulatory arrest in 1. In 8 patients a single internal mammary artery was used as the total inflow with a saphenous vein graft brought off the internal mammary artery to one or more distal left-sided coronary vessels. Bilateral internal mammary arteries were used in 2 other patients. Operative mortality was zero. There was one perioperative myocardial infarction and one transient stroke without sequelae. All patients have done well from 1 to 6 years postoperatively. These data support the use of internal mammary arteries as single or bilateral proximal conduits for other venoarterial bypass grafts when the aorta is extensively diseased either by calcification or dissection.