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

Abstract

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.

Keywords: Coronary artery bypass grafting, Cardiopulmonary bypass, Severe atherosclerotic aorta, Porcelain aorta, Stroke, Mortality

Core Tip: Porcelain aorta (PA) is a serious atherosclerotic disease that prevents manipulation of the aorta, and it is seen in 2% to 9.3% of the patients undergoing elective coronary artery bypass grafting (CABG). Although various mechanisms have been proposed to explain the development of stroke in cardiac surgery, embolic events resulting from manipulation of the ascending aorta are the main cause of stroke. Perioperative stroke is still among the most crucial complications of CABG surgery with its high patient morbidity and mortality. The best approach to prevent embolic events is the use of alternative surgical techniques which aim to minimize or eliminate the manipulation of a severely atherosclerotic or completely calcified aorta. Here, surgical strategies which are used for the management of patients with PA are summarized.