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[Modification of the surgical strategy based on intraoperative echographic findings of atherosclerotic ascending
Insights
Intraoperative echography identifies atherosclerotic lesions in the ascending aorta, guiding cardiac surgery to prevent atheroembolic complications like stroke. This imaging is more sensitive than CT for detecting plaques, enabling safer surgical strategies.
Area of Science:
- Cardiovascular Surgery
- Diagnostic Imaging
- Vascular Medicine
Background:
- Cardiac surgery involving the ascending aorta carries a risk of atheroembolic complications, such as stroke, due to manipulation of atherosclerotic plaques.
- Existing imaging modalities like CT scans may not effectively detect atheromatous plaques in the ascending aorta.
- Preventing atheroembolism is crucial for improving patient outcomes during procedures like coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the utility of intraoperative echography in identifying atherosclerotic lesions of the ascending aorta in patients undergoing cardiac surgery.
- To determine if intraoperative echography can guide surgical strategies to prevent atheroembolic complications.
- To compare the effectiveness of intraoperative echography with CT scans for detecting aortic atherosclerosis.
Main Methods:
- Intraoperative echography was routinely performed on the ascending aorta of 55 patients (mean age 67.7 years) undergoing cardiac surgery.
- Surgical strategies, including cannulation site and clamping techniques, were modified based on echographic findings of atherosclerotic lesions.
- Correlation between CT findings and echographic results was analyzed; sensitivity of both methods for plaque detection was assessed.
Main Results:
- Atherosclerotic lesions were identified in 7 patients (13%) using intraoperative echography, with 2 emergent cases.
- Surgical modifications, such as arch or femoral cannulation and single or partial aortic clamping away from lesions, were successfully employed.
- Intraoperative echography demonstrated higher sensitivity in detecting atheromatous plaques compared to enhanced CT scans.
Conclusions:
- Intraoperative echography is a sensitive and effective tool for diagnosing atherosclerotic lesions in the ascending aorta during cardiac surgery.
- Modifying surgical strategies based on intraoperative echography findings can prevent atheroembolic complications.
- Intraoperative echography facilitates safer cardiac procedures by enabling precise placement of cannulae and clamps away from diseased aortic segments.
Abstract:
To prevent the atheroembolic complications such as brain infarction due to the manipulation of atherosclerotic ascending aorta during cardiac surgery, the ascending aorta of 55 patients including 6 emergencies (mean age: 67.7 +/- 6.9 years, valvular disease: n = 12, ischemic heart disease only or combined with valvular disease: n = 43) were evaluated with intraoperative echography as a routine, to enable a proper placement of the cannulae, clamp etc. Irregular elevated lesions into the aortic lumen from the intima were identified in 7 patients (13%, mean age: 71.0 +/- 6.9 years) of ischemic heart disease, which included 2 emergent cases. Arch cannulation was employed in 3 patients with wide-spread lesions on the posterior wall and femoral cannulation was done in 1 patient with wide-spread lesions on the anterior wall. Two of these patients received CABG with in situ arterial conduits under ventricular fibrillation, and the other 2 patients received CABG with aortic cross clamping at the lesion-free site during proximal anastomosis of vein grafts (single clamp technique). Two patients with localized lesion were done CABG with partial aortic clamping and one of them had cerebral infarction during the operation. We recognized that manipulation of the ascending aorta has to be done with a meticulous care and well away from the diseased site. In another patient with localized lesion, the arch cannulation and the single clamp technique were used 2 cm away from that lesion. The brain infarcted patient completely recovered without any sequelae and the others also had no atheroembolic complications. Although calcified lesions on CT were correlated with atheromatous lesions on echogram (p = 0.004), these atheromatous plaques were not detected by enhanced CT, except in only one patient. For screening of the atherosclerosis of ascending aorta, the CT examination was not so effective and the intraoperative echography was the most sensitive and could be easily accomplished. In conclusion, in order to prevent the atheroembolism that might occur due to the improper manipulation of the diseased ascending aorta during usual procedures, surgical strategies have to be modified according to the position, extent and quality of the atherosclerotic lesions, diagnosed by intraoperative echoscanning of the aorta.