Clampless technique during coronary artery bypass grafting for proximal anastomoses in the hostile aorta

Abstract

The incidence of stroke in patients undergoing coronary artery bypass grafting increases sharply in the face of significant atherosclerotic disease of the ascending aorta. We use a technique that allows full revascularization for this cohort of patients, while minimizing cerebral embolic risk. Methods: Intraoperative epiaortic ultrasound was used to screen for moderate or severe atherosclerotic disease of the ascending aorta and to precisely identify safe areas for cannulation and proximal anastomoses. By using a mildly hypothermic fibrillating technique, distal revascularization was then performed without clamping the aorta. Proximal anastomoses were accomplished under brief periods of circulatory arrest. Results: We routinely use this technique and examined our results in 71 consecutive patients found to have grade 3 or greater atherosclerotic plaque of the ascending aorta. This represented approximately 10.0% of our total population who underwent coronary artery bypass grafting over a 32-month period from January 2007 to September 2009. One patient (1.4%) had a mild stroke that resolved, and there were no other neurologic complications. Conclusions: We have found that clampless fibrillating heart surgery with circulatory arrest for proximal anastomoses is a safe and effective technique for revascularizing patients with significant ascending aortic disease who are at high risk for cerebral embolic complications.

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

“…The “no-touch” technique avoids all types of clamps in the aorta. Also when using this technique, no cardioplegia is applied, no grafts are anastomosed to the aorta, and deep hypothermia is not necessary[ 20 , 21 ]. Anaortic or no-touch techniques without aortic manipulation can significantly improve the development of neurologic complications by avoiding aortic maneuvers known to cause embolism[ 22 , 23 ].…”

“…One of the methods used to achieve optimal coronary revascularization is hypothermic ventricular fibrillation or hypothermic fibrillatory arrest[ 4 , 21 ]. The hypothermic fibrillatory arrest also allows easy proximal anastomosis to a disease-free area of the ascending aorta in patients with a high risk of cerebral embolic complications and significant ascending aortic disease[ 21 , 27 ]. Gaudino et al [ 4 ] could not find a difference between hypothermic ventricular fibrillation and beating heart in terms of the overall in-hospital mortality rate.…”

“…The best approach to prevent cerebral embolic complications is to modify the surgical techniques to minimize or eliminate the manipulation of a severely atherosclerotic or fully calcified aorta. To safely perform CABG operations with low morbidity and mortality rates, various methods including the use of axillary/subclavian artery[ 15 - 17 ], femoral artery (FA)[ 4 , 18 ], or innominate artery (IA)[ 15 , 19 ] for cannulation, utilization of aortic “no-touch” or anaortic off-pump CABG surgery[ 4 , 20 - 23 ], use of in-situ pedicle arterial grafts[ 24 - 26 ], hypothermic ventricular fibrillation[ 4 , 21 , 26 , 27 ] and carrying out the proximal anastomoses in different anatomic locations[ 28 - 30 ], have been suggested. This review examines the relevant studies on patients who have a severe atherosclerotic disease of the ascending aorta or PA, and who need to undergo CABG surgery.…”

Strategy for Porcelain Ascending Aorta in Cardiac Surgery

“…Hypothermic fibrillatory arrest without clamping is also useful. 9,36) Salenger et al 36) retrospectively examined the outcome of a non-clamp technique for coronary revascularization in 71 consecutive patients with severe calcification of the ascending aorta. Distal revascularization was accomplished using mildly hypothermic (30-32°C) noncardioplegic myocardial preservation with elective ventricular fibrillation, while proximal anastomoses were performed during brief periods of circulatory arrest.…”