Off-pump coronary artery revascularization: Ideal indication for patients with porcelain aorta and calcification of great vessels

Patients with porcelain aorta and severe calcification of the great vessels are a challenging dilemma for the cardiovascular surgeon regarding bypass technique, choice of conduit, and selection of proximal anastomotic sites due to the high incidence of devastating thromboembolization and aortic injury. No currently proposed surgical approach avoids manipulation of the heavily calcified ascending aorta. Three patients presented with unstable angina and decreased ventricular function secondary to significant left main coronary artery stenosis and 3-vessel coronary artery disease. In addition to the coronary artery disease, severely calcified ascending aorta and great vessels were discovered. One patient presented with near total distal abdominal aortic occlusion, severe peripheral vascular disease, history of stroke, and carotid endarterectomy. Surgical coronary revascularization was indicated. Coronary artery bypass grafting using internal thoracic artery and greater saphenous vein composite arterial inflow grafts in combination with off-pump beating heart surgery was successfully used. Cardiopulmonary bypass and clamping of the aorta was avoided. No new neurologic deficit was observed. Coronary revascularization with internal thoracic artery composite grafts and avoiding cardiopulmonary bypass and clamping the calcified aorta is an effective method to prevent clamp injury and thromboembolization. Off-pump coronary artery bypass grafting seems to be an ideal indication in patients with porcelain aorta because the surgical techniques of "no-touch" and "no-cannulation" can be applied.