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.

Concomitant anaortic OPCAB and transfemoral TAVR for high‐risk patients: A case series

“…These cerebrovascular events arise from the disruption and dislodgment of atheromatous emboli by manipulation of the ascending aorta 14,15 . The risk is determined by the extent and severity of atherosclerotic aortic disease 5 . Van der Linden have found a nearly five‐fold increase in peri‐operative stroke in patients with atherosclerotic ascending aorta disease compared with those without (8.7% vs. 1.8%, p < .001) 27 .…”

“…Incidence of peri-operative stroke after CABG in the general population is 0.48%-2.9%. 5 These cerebrovascular events arise from the disruption and dislodgment of atheromatous emboli by manipulation of the ascending aorta. 14,15 The risk is determined by the extent and severity of atherosclerotic aortic disease.…”

“…Indeed, severe aortic stenosis requiring intervention is associated with significant coronary artery disease in up to 50% of cases 4 . Porcelain aorta has been found in 7.5% of all patients evaluated for AS and in up to 9.3% of patients undergoing coronary artery bypass grafting (CABG) 5 …”

“…5 These are diseases of the elderly, all are increasingly recognized in patients older than 60 and their prevalence and severity worsen with increasing age. 1,5 Clinicians and surgeons alike must be prepared to manage these aging high-risk patients with concomitant atherosclerotic disease as the elderly are the fastest-growing segment of the population. 6 Life expectancy is predicted to increase from 79.7 years in 2017 to 85.6 years, with people >65 forecasted to make up 1/4 of the US population by 2060.…”

“…4 Porcelain aorta has been found in 7.5% of all patients evaluated for AS and in up to 9.3% of patients undergoing coronary artery bypass grafting (CABG). 5 These are diseases of the elderly, all are increasingly recognized in patients older than 60 and their prevalence and severity worsen with increasing age. 1,5 Clinicians and surgeons alike must be prepared to manage these aging high-risk patients with concomitant atherosclerotic disease as the elderly are the fastest-growing segment of the population.…”