Sirin Gokce
Department of Cardiovascular Surgery, Biruni University, Istanbul 34010, Turkey.
World J Cardiol. 2021 Aug 26;13(8):309-324. doi: 10.4330/wjc.v13.i8.309.
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.
瓷化主动脉（PA）是一种无症状的动脉粥样硬化疾病，其特征是主动脉整个周长出现环形钙化。在接受择期冠状动脉旁路移植术（CABG）的患者中，其发生率为2%至9.3%，会导致无法对升主动脉进行操作。已有明确证据表明，在CABG手术过程中所见及检测到的大多数栓子发生在主动脉交叉钳夹和主动脉侧钳夹期间。对瓷化或严重动脉粥样硬化的主动脉进行操作会增加围手术期卒中的风险。CABG术后卒中的发生率在0.48%至2.9%之间，且该风险与动脉粥样硬化疾病的范围和严重程度相关。传统的CABG手术包括一系列步骤，其中有升主动脉插管、对主动脉应用交叉钳夹以及对主动脉进行部分钳夹以建立近端吻合。因此，在涉及插管、钳夹或近端吻合且不可避免要对主动脉进行操作的手术中，对动脉粥样硬化性主动脉斑块进行术前评估至关重要。尽管许多外科医生仍依赖术中手动触诊主动脉，但这种方法敏感性很低，会低估动脉粥样硬化疾病的严重程度。包括术前计算机断层扫描或术中主动脉外超声检查在内的成像方法能够根据动脉粥样硬化的严重程度调整手术技术。已描述了多种手术技术来降低严重动脉粥样硬化性升主动脉患者发生可能导致脑血管事件的动脉粥样硬化栓塞的风险。不进行主动脉操作的非主动脉或“无接触”技术可通过避免已知会导致栓子的主动脉操作，显著降低神经并发症的发生。在严重动脉粥样硬化疾病或其他因素妨碍安全使用升主动脉的情况下，对手术技术进行调整，例如改用不同的插管部位，包括腋/锁骨下动脉、股动脉和无名动脉，或使用低温室颤和原位带蒂动脉移植物，或在其他解剖位置进行近端吻合，将能够在瓷化主动脉患者中安全地进行CABG手术，且发病率和死亡率较低。
