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The Journal of Thoracic and Cardiovascular Surgery, Vol 102, 546-553, Copyright © 1991 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
NL Mills and CT Everson
Analysis of 1735 patients who underwent coronary artery bypass grafting
from January 1981 through December 1988 revealed 152 (8.8%) patients with
mild (4.5%), moderate (2.2%), or severe (2.0%) atherosclerosis of the
ascending aorta. Three distinct pathologic patterns were found. The
prevalence of stroke in patients with the severe type of aortic disease
prompted development of a new operative technique that has been used in 16
patients. It involves a "no-touch" technique of the ascending aorta
whereupon the proximal saphenous vein anastomoses are performed end to side
to internal mammary artery grafts. Ages ranged from 49 to 80 years (mean
68.9). The 16 patients had 62 distal artery and vein anastomoses and 26
proximal saphenous vein-internal mammary end-to-side anastomoses. Internal
mammary artery free flows ranged from 130 to 420 ml/min. Two hospital
deaths were unrelated to the technique. There have been no strokes or
recurrences of angina. An inordinately high incidence of main left coronary
disease (50%), significant carotid disease (79%), and abdominal aortic
occlusive or aneurysm disease (93%) was discovered. Ascending aortic
atherosclerosis must be suspected in all coronary bypass patients with
associated significant carotid, abdominal aortic, and main left coronary
artery disease, aortic wall irregularity on ascending aortic angiography,
adhesions between the ascending aorta and its adventitia, pale appearance
of the ascending aorta, and minimal bleeding of an aortic cannulation stab
wound. A "no- touch" technique that avoids any manipulation of the
ascending aorta and that uses the internal mammary arteries as the sole
source of blood supply for coronary bypass is an effective method to
prevent aortic clamp injury, "trash heart," or stroke from severe ascending
aortic disease. Preoperative angiographic visualization of the ascending
aorta of all patients undergoing coronary artery bypass is mandatory.
ARTICLES
Atherosclerosis of the ascending aorta and coronary artery bypass. Pathology, clinical correlates, and operative management
Department of Surgery, Cardiology Center, New Orleans, LA 70072.
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