Coronary Bypass Grafting With Totally Calcified or
Acutely Dissected Ascending Aorta
Pamela S. Peigh, MD, Verdi J. DiSesa, MD, John J. Collins, Jr, MD, and
Lawrence H. Cohn, MD
Division of Cardiac Surgery, Brigham and Women’s Hospital, and Department of Surgery, Harvard Medical School, Boston,
Massachusetts
From August 1984 through November 1988, 10 of 2,658
patients undergoing coronary artery bypass grafting had
ascending aortic disease that was not amenable to prox-
imal anastomoses for coronary bypass grafting. This was
due to a calcified aorta in 6 and acute aortic dissection in
4. There were 5 male and 5 female patients with a mean
age of 71 years. Cannulation site was the femoral artery
in 5, ascending aorta in 3, and aortic arch in 2. Profound
hypothermia and ventricular fibrillation, with no cross-
clamp or cardioplegia, was used in 9 patients, and
circulatory arrest in 1. In 8 patients a single internal
mammary artery was used as the total inflow with a
C ardiac operations performed on patients whose as-
cending aorta is difficult, either from calcification or
dissection, are technically challenpng and associated with
a high morbidity. Stoney and associates [l] reported
unexpected poor results in low-risk patients most fre-
quently from manipulation of a diseased ascending aorta.
With recognized disease of the ascending aorta and trans-
verse aortic arch, cerebral injury has been shown to occur
after cardiopulmonary bypass in more than 10% of pa-
tients (21.
We became interested in the operative management of
the severely diseased aorta after Mills’ [3] report on this
subject as the age of our patient population began to rise
and we saw a concomitant increase in postoperative
stroke rate. We reviewed our experience with manage-
ment of the difficult aorta in coronary artery bypass
operations in which the ascending aorta was not used for
any proximal anastomosis to determine the utility of this
approach in terms of early and late morbidity.
Material and Methods
We analyzed the records of the 2,658 consecutive patients
who underwent coronary artery bypass grafting at the
Brigham and Women’s Hospital from August 1984
through November 1988. In 10 (0.4%)of these patients the
aorta was not used as the inflow portion for any conduit.
There were 5 male and 5 female patients. The ages ranged
Accepted for publication Sep 18, 1990.
Presented at the Thirty-ninth Annual Scientific Session of the American
College of Cardiology, New Orleans, LA, March 18-22, 1990.
Address reprint requests to Dr Cohn, Division of Cardiac Surgery,
Brigham and Women‘s Hospital, 75 Francis St, Boston, MA 02115.
0 1991 by The Society of Thoracic Surgeons
saphenous vein graft brought off the internal mammary
artery to one or more distal left-sided coronary vessels.
Bilateral internal mammary arteries were used in 2 other
patients. Operative mortality was zero. There was one
perioperative myocardial infarction and one transient
stroke without sequelae. All patients have done well
from 1 to 6 years postoperatively. These data support the
use of internal mammary arteries as single or bilateral
proximal conduits for other venoarterial bypass grafts
when the aorta is extensively diseased either by calcifi-
cation or dissection.
(Ann Thorac Surg 1991;51:102-4)
from 65 to 78 years, with a mean of 71 years. In eight
instances there was severe associated peripheral vascular
disease-five in the femoropopliteal position and three in
the carotids. In 6 patients, this was their first coronary
artery bypass grafting; for 3 patients, this was their
second operation for coronary artery bypass grafting; and
in 1 patient, this operation followed a previous median
sternotomy for attempted coronary artery bypass grafting
which was aborted after the calcified aorta was palpated.
In 6 patients, the wall of the ascending aorta was totally or
near-totally calcified. In 4 patients, there was an acute
aortic dissection: one iatrogenic, one iatrogenic from an-
other hospital, and two spontaneous.
In all cases manipulation of the ascending aorta was
avoided. The femoral artery was used for cannulation in 5
patients, an isolated ”soft spot” very distal on the ascend-
ing aorta in 3 patients, and the lesser curvature of the
transverse arch in 2 patients. In 8 patients, myocardial
protection was provided by profound systemic hypother-
mia and ventricular fibrillation without cross-clamp or
cardioplegia. In 1 patient with aortic dissection, profound
systemic hypothermia was used along with cardioplegia,
and in 1 patient it was necessary to employ circulatory
arrest to replace a segment of distal ascending aorta where
a dissection had occurred at the cannulation site.
The revascularization operations are summarized in
Table 1. In 8 patients, a single internal mammary artery
(IMA) was used as the inflow conduit for eight IMA-to-
coronary artery anastomoses. To these eight IMAs, the
greater saphenous vein was attached end-to-side, and
then it was anastomosed to one or more distal coronary
arteries for a total of ten distal anastomoses. The cephalic
vein was used in a similar fashion to one distal coronary
0003-4975/91/$3.50
Ann Thorac Surg PElGH ET AL 103
1991;51:1024 CABG WITH DIFFICULT AORTA

Table 1. Revascularization Operative Data

Patient Age Associated Vascular
No. Sex (Y) Disease Operation Complications Discharged
1 M 78 Femoropopliteal RIMA-RCA, LIMA-LAD ... Yes
2 M 66 .. LIMA-LAD, SVGOMB GI bleed Yes
3 F 74 ... RIMA-LAD, CEPH-PDA ... Yes
4 F 71 Carotid, femoropopliteal LIMA-LAD, SVGOMB- ... Yes
OMB
5 M 71 ... RIMA-RCA, SVG-OMB, Yes
LIMA-LAD
6 F 65 Carotid, femoropopliteal RIMA-LAD, SVG-RCA Yes
7 F 71 Femoropopliteal LIMA-LAD, SVG-OMB Yes
8 M 75 Carotid, femoropopliteal LIMA-LAD, SVG-LADDI- Frontal lobe stroke Yes
OMB,
9 F 65 ... LIMA-LAD, SVG-FDA Subendocardial MI Yes
10 M 70 ... LIMA-LAD, SVG-OMBI- ... Yes
OMB,
CEPH = cephalic vein; GI = gastrointestinal; LAD = left anterior descending artery; LADD, = first diagonal artery; LIMA = left internal
mammary artery; MI = myocardial infarction; OMB, = first obtuse marginal artery; OMB, = second obtuse marginal artery; PDA =
posterior descending artery; RCA = right coronary artery; RlMA = right internal mammary artery; SVG = saphenous vein graft.

artery. Internal mammary artery anastomoses were car-

ried out with running 7-0 Prolene (Ethicon, Somerville,
NJ) sutures.
In 2 patients, bilateral IMAs were used as the inflow
conduit for four IMA-to-coronary artery anastomoses.
The greater saphenous vein was attached end-to-side to
one of these IMAs and anastomosed to one distal coro-
nary artery (Fig 1). In 1 patient, no venous conduits were
used at all. Complete revascularization was accomplished
in 8 of 10 patients.

Results
Operative survival was 100%. There were two postoper-
ative complications. A subendocardial myocardial infarc-
tion occurred in 1 patient with aortic dissection. There
was also one small left frontal lobe stroke in a patient with
a calcified aorta and bilateral carotid disease in whom no
cross-clamp was used. His recovery after right arm weak-
ness without residua was completed during his hospital-
ization.
Follow-up has ranged from 1 to 6 years, with a mean of
4 years. Nine patients are still alive and doing well. One
patient died at 4 years postoperatively of unknown
causes. There have been no reoperations.

Comment
The data suggest that the use of the IMA to provide total
inflow for all bypass grafts in patients with totally calcified
or acutely dissected ascending aortas, along with minimal
other manipulation of the aorta, provides a safe solution
to a potentially lqthal technical problem that up to now
has had no universally successful solution.
A number of techniques have been described for deal-
ing with the diseased ascending aorta during coronary
Fig 1 . Bilateral internal mammary artery grafts may be used in con-
junction with saphenous vein grafts when the ascending aorta is se-
verely diseased. The saphenous vein grafts are anastomosed proximally
to the proximal internal mammary artery end to side. (Reproduced
with permission from: Mills N . Physiologic and technical aspects of
internal mammary artey-coronary artery bypass grafts. In: Cohn
LH, ed. Modern techniques in surgery: cardiaclthoracic surgery. M t .
Kisco, NY: Futura, 1982:48.17.)
104 PEIGH ET AL
CABG WITH DIFFICULT AORTA
artery bypass. Performing all coronary artery bypass
grafts under one cross-clamp and avoiding a reapplication
of a partial occlusion clamp for proximal anastomoses is a
widely used technique. Robicsek and Rubenstein [4] de-
scribed placing all proximal vein graft anastomoses onto a
Teflon patch graft placed in a longitudinal aortotomy to
avoid compromising the anastomoses. Culliford and as-
sociates [5] described an aggressive technique of circula-
tory arrest and then ascending aortic endarterectomy.
Holland and Hieb [6] and Weinstein and Killen [7] have
both individually reported using the innominate artery as
the inflow portion for proximal vein graft anastomoses.
Murphy and Hatcher [PI]reported extending the length
of the IMA to reach the back of the heart by anastomosing
end-to-end a piece of saphenous vein graft to the IMA.
This allowed leaving the IMA in situ and avoidance of
clamping the ascending aorta. Mills [3] was the first to
describe attaching one to three saphenous vein grafts to
the IMA to provide the total inflow for multiple coronary
artery obstructions in this setting.
Mills and associates [9] have also tried to predict pa-
tients with the difficult aorta. At risk for having a difficult
aorta are those patients with carotid or abdominal aortic
disease and patients whose angiograms show aortic wall
irregularity. Five of our 10 patients had clinically signifi-
cant peripheral vascular disease. Though intraoperatively
there are some physical signs of the calcified ascending
aorta, transesophageal echocardiography may be the best
way to diagnose this condition (91.
Is the IMA capable of supplying enough blood to
provide total inflow for revascularization in this scenario?
Dion [lo] looked at this question in 531 IMA anastomoses
that were performed in a sequential fashion. In the 319
patients that underwent thallium stress testing, there was
no ischemia demonstrated in the region of the sequential
IMAs at 6 months. Further, Hodgson and associates [ l l ]
looked at coronary flow reserve in patients with sequen-
tial IMAs by measuring reactive hyperemia using digital
angiography and comparing basal flow with flow 10 to 15
seconds later, which reflects contrast-induced hyperemia.
At postoperative day 25, there was no difference between
coronary flow reserve at the proximal versus the distal
sequential anastomosis. Further, there was no difference
in the coronary flow reserve to the vascular bed distal to
either a sequential IMA, a single IMA, a single saphenous
vein graft, or a nonstenotic native coronary artery. Mills
and associates [9] have also done exercise testing as well
as postoperative angography in many patients with only
Ann Thorac Surg
1991;51:1024
IMA inflow to multiple coronary arteries with excellent
results. Five of our 10 patients have had postoperative
stress testing and 2 others had "clinical" stress tests
provided by gastrointestinal bleeding, and all demon-
strated no myocardial ischemia.
In conclusion, these data support the use of the IMA to
provide total inflow for all bypass grafts in patients with a
totally calcified or acutely dissected ascending aorta. This
method provides a satisfactory solution to a potentially
lethal technical problem during coronary revasculariza-
tion.
References
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