General Thoracic and Cardiovascular Surgery

, Volume 61, Issue 6, pp 301–313 | Cite as

Shaggy and calcified aorta: surgical implications

  • Ikuo Fukuda
  • Kazuyuki Daitoku
  • Masahito Minakawa
  • Wakako Fukuda
Current Topics Review Article


Atheroembolism is an emerging problem in cardiovascular surgery, especially in elderly patients. Severe atherosclerosis of the thoracic aorta usually reflects systemic atherosclerosis. Aggressive preoperative and intraoperative evaluation of the aorta using enhanced CT, transesophageal echocardiography and epiaortic ultrasound is important in elderly patients as well as those with systemic atherosclerosis. To prevent atheroembolism, it is important to select an adequate arterial perfusion site and to avoid touching the diseased aorta until circulatory arrest. In atherosclerotic aortic arch aneurysm, central cannulation under ultrasound guidance and directing the dispersive cannula toward the aortic root is a simple and effective perfusion strategy. Axillary perfusion is useful as an alternative to central cannulation in atherosclerotic aortic disease, but special care is necessary to avoid complications when the patient has a small axillary artery or flail atheroma around the arch vessels. In femoral artery perfusion, retrograde perfusion may induce paradoxical cerebral embolism, but the incidence of stroke is comparable with axillary perfusion when there is adequate preoperative screening using transesophageal echography. Circulatory arrest with/without cerebral perfusion is another important strategy when the aorta has severe atherosclerosis. Recent literature has shown that mild hypothermia may be safe for anterior cerebral perfusion during circulatory arrest, but optimal flow rates and time limitations are unknown. A simple calcified aorta called “porcelain aorta” may be managed by circulatory arrest, local debridement and the clamp method. Several surgical options are proposed for this clinical entity but their use will diminish in the future because of transcatheter valve replacement.


Atheroembolism Stroke Mobile atheroma Axillary perfusion Aortic perfusion 


  1. 1.
    Blauth CI. Macroemboli and microemboli during cardiopulmonary bypass. Ann Thorac Surg. 1995;59:1300–3.PubMedGoogle Scholar
  2. 2.
    Blauth CI, Cosgrove DM, Webb BW, Ratliff NB, Boylan M, Piedmonte MR, et al. Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery. J Thorac Cardiovasc Surg. 1992;103:1104–12.PubMedGoogle Scholar
  3. 3.
    Okada K, Omura A, Kano H, Sakamoto T, Tanaka A, Inoue T, et al. Recent advancements of total aortic arch replacement. J Thorac Cardiovasc Surg. 2012;14:139–45.Google Scholar
  4. 4.
    Minatoya K, Ogino H, Matsuda H, Sasaki H, Tanaka H, Kobayashi J, et al. Evolving selective cerebral perfusion for aortic arch replacement: high flow rate with moderate hypothermic circulatory arrest. Ann Thorac Surg. 2008;86:1827–31.PubMedGoogle Scholar
  5. 5.
    Kazui T, Yamashita K, Washiyama N, Terada H, Bashar AH, Suzuki K, et al. Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg. 2007;83:S796–8.PubMedGoogle Scholar
  6. 6.
    Thomas M, Li Z, Cook DJ, Greason KL, Sundt TM. Contemporary results of open aortic arch surgery. J Thorac Cardiovasc Surg. 2012;144:838–44.PubMedGoogle Scholar
  7. 7.
    Wareing TH, Davila-Roman VG, Barzilai B, Murphy SF, Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg. 1992;103:453–62.PubMedGoogle Scholar
  8. 8.
    Anitschkow NN, Chalatov S. Ueber experimentelle Choleserinsteatose und ihre Bedeutung fur die Entstehung eini ger pathologischer Prozesse. Zentralbl Allg Pathol. 1913;24:1–9.Google Scholar
  9. 9.
    Steinberg D. An interpretive history of the cholesterol controversy: part I. J Lipid Res. 2004;45:1583–93.PubMedGoogle Scholar
  10. 10.
    Klimov AN, Rodionova LP, Petrova-Maslakova LG. Experimental atherosclerosis induced by repeated intravenous ad- ministration of hypercholesterolaemic serum. Cor Vasa. 1966;8:225–30.PubMedGoogle Scholar
  11. 11.
    Culliford AT, Colvin SB, Rohrer K, Baumann FG, Spencer FC. The atherosclerotic ascending aorta and transverse arch: a new technique to prevent cerebral injury during bypass: experience with 13 patients. Ann Thorac Surg. 1986;41:27–35.PubMedGoogle Scholar
  12. 12.
    Ohteki H, Itoh T, Natsuaki N, Minato N, Suda H. Intraoperative ultrasonic imaging of the ascending aorta in ischemic heart disease. Ann Thorac Surg. 1990;50:539–42.PubMedGoogle Scholar
  13. 13.
    Barzilai B, Saffitz JE, Miller JG, Sobel BE. Quantitative ultrasonic characterization of the nature of atherosclerotic plaques in human aorta. Circ Res. 1987;60:459–63.PubMedGoogle Scholar
  14. 14.
    Marshall WG, Barzilai B, Kouchoukos NT, Saffitz J. Intraoperative ultrasonic imaging of the ascending aorta. Ann Thorac Surg. 1989;48:339–44.PubMedGoogle Scholar
  15. 15.
    Tunick PA, Kronzon I. Protruding atherosclerotic plaque in the aortic arch of patients with systemic embolization: a new finding seen by transesophageal echocardiography. Am Heart J. 1990;120:658–60.PubMedGoogle Scholar
  16. 16.
    Amarenco P, Duyckaerts C, Tzourio C, Hénin D, Bousser MG, Hauw JJ. The prevalence of ulcerated plaques in the aortic arch in patients with stroke. N Engl J Med. 1992;326:221–5.PubMedGoogle Scholar
  17. 17.
    Amarenco P, Cohen A, Tzourio C, Bertrand B, Hommel M, Besson G, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331:1474–9.PubMedGoogle Scholar
  18. 18.
    The French Study of Aortic Plaques in Stroke Group. Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke. N Engl J Med. 1996;334:1216–21.Google Scholar
  19. 19.
    Ura M, Sakata R, Nakayama Y, Goto T. Ultrasonographic demonstration of manipulation-related aortic injuries after cardiac surgery. J Am Coll Cardiol. 2000;35:1303–10.PubMedGoogle Scholar
  20. 20.
    Ueda T, Shimizu H, Moro K, Shin H, Yozu R, Kashima I, et al. Complications associated with clamping the aorta between the left common carotid artery and left subclavian artery. Ann Thorac Surg. 2000;70:558–61.PubMedGoogle Scholar
  21. 21.
    Kapetanakis EI, Stamou SC, Dullum MK, Hill PC, Haile E, et al. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study. Ann Thorac Surg. 2004;78:1564–71.PubMedGoogle Scholar
  22. 22.
    Yamanaka K, Miki S, Kusuhara K, Okita Y, Tahata T. The prevalence of atherosclerotic lesions in the aortic arch. Nihon Kyobu Geka Gakkai Zasshi (In Japanese). 1995;43:432–7.PubMedGoogle Scholar
  23. 23.
    Calafiore AM, Di Mauro M, Teodori G, et al. Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. Ann Thorac Surg. 2002;73:1387–93.PubMedGoogle Scholar
  24. 24.
    Berens ES, Kouchoukos NT, Murphy SF, Wareing TH. Preoperative carotid artery screening in elderly patients undergoing cardiac surgery. J Vasc Surg. 1992;15:313–21.PubMedGoogle Scholar
  25. 25.
    Fukuda I, Gomi S, Watanabe K, Seita J. Carotid and aortic screening for coronary artery bypass grafting. Ann Thorac Surg. 2000;70:2034–9.PubMedGoogle Scholar
  26. 26.
    Bowles JB, Lee JD, Dang CR, et al. Coronary artery bypass performed without use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results. Chest. 2001;119:25–30.PubMedGoogle Scholar
  27. 27.
    Kronzon I, Tunick PA. Transesophageal echocardiography as a tool in the evaluation of paients with embolic disorders. Prog Cardiovasc Dis. 1993;36:39–60.PubMedGoogle Scholar
  28. 28.
    Fukuda I, Minakawa M, Fukui K, Taniguchi S, Daitoku K, Suzuki Y, et al. Breakdown of atheromatous plaque due to shear force from arterial perfusion cannula. Ann Thorac Surg. 2007;84:e17–8.PubMedGoogle Scholar
  29. 29.
    Tunick PA, Lackner H, Katz ES, Culliford AT, Giangola G, et al. Multiple emboli from a large aortic arch thrombus in a patient with thrombotic diathesis. Am Heart J. 1992;124:239–41.PubMedGoogle Scholar
  30. 30.
    Lozano P, Gomez FT, Julia J, M-Rimbau E, Garcia F. Recurrent embolism caused by floating thrombus in the thoracic aorta. Ann Vasc Surg. 1998;12:609–11.PubMedGoogle Scholar
  31. 31.
    Masuda J, Yutani C, Ogata J, Kuriyama Y, Yamaguchi T. Atheromatous embolism in the brain: a clinicopathologic analysis of 15 autopsy cases. Neurology. 1994;44:1231–7.PubMedGoogle Scholar
  32. 32.
    Kronzon I, Tunick PA. Aortic atherosclerotic disease and stroke. Circulation. 2006;114:63–75.PubMedGoogle Scholar
  33. 33.
    van der Linden J, Hadjinikolaou L, Bergman P, Lindblom D. Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerotic disease in the ascending aorta. J Am Coll Cardiol. 2001;38:131–5.PubMedGoogle Scholar
  34. 34.
    Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol. 1992;20:70–7.PubMedGoogle Scholar
  35. 35.
    Kazmier FJ. Shaggy aorta syndrome and disseminated atheromatous embolization. In: Bergan JJ, Yao JST, editors. Aortic Surgery. Philadelphia: W.B. Saunders Company; 1989. p. 189–94.Google Scholar
  36. 36.
    Hollier LH, Kazmier FJ, Ochsner J, Bowen JC, Procter CD. “Shaggy” aorta syndrome with atheromatous embolization to visceral vessels. Ann Vasc Surg. 1991;5:441–4.Google Scholar
  37. 37.
    Tunick PA, Nayar AC, Goodkin GM, Mirchandani S, Francescone S, Rosenzweig BP. et al Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque. Am J Cardiol. 2002;90:1320–5.PubMedGoogle Scholar
  38. 38.
    Dávila-Román VG, Barzilai B, Wareing TH, Murphy SF, Schechtman KB, Kouchoukos NT. Atherosclerosis of the ascending aorta: prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke. 1994;25:2010–6.PubMedGoogle Scholar
  39. 39.
    Djaiani G, Fedorko L, Borger M, Mikulis D, Carroll J, Cheng D, et al. Mild to moderate atheromatous disease of the thoracic aorta and new ischemic brain lesions after conventional coronary artery bypass graft surgery. Stroke. 2004;35:e356–8.PubMedGoogle Scholar
  40. 40.
    Okada K, Omura A, Kano H, Inoue T, Oka T, Minami H, et al. Effect of atherothrombotic aorta on outcomes of total aortic arch replacement. J Thorac Cardiovasc Surg. 2012 May 8. [Epub ahead of print].Google Scholar
  41. 41.
    Coselli JS, Crawford ES. Aortic valve replacement in the patient with extensive calcification of the ascending aorta (the porcelain aorta). J Thorac Cardiovasc Surg. 1986;91:184–7.PubMedGoogle Scholar
  42. 42.
    Hosoda Y, Watanabe M, Hirooka Y, Ohse Y, Tanaka A, Watanabe T. Significance of atherosclerotic changes of the ascending aorta during coronary bypass surgery with intraoperative detection by echography. J Cardiovasc Surg (Torino). 1991;32:301–6.Google Scholar
  43. 43.
    Mills NL, Everson CT. Atherosclerosis of the ascending aorta and coronary artery bypass: pathology, clinical correlates, and operative management. J Thorac Cardiovasc Surg. 1991;102:546–53.PubMedGoogle Scholar
  44. 44.
    Ergin MA, Galla JD, Lansman L, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta: determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg. 1994;107:788–97.PubMedGoogle Scholar
  45. 45.
    Weinstein GS. Left hemispheric strokes in coronary surgery: implications for end-hole aortic cannulas. Ann Thorac Surg. 2001;71:128–32.PubMedGoogle Scholar
  46. 46.
    Minakawa M, Fukuda I, Yamazaki J, Fukui K, Yanaoka H, Inamura T. Effect of cannula shape on aortic wall and flow turbulence: hydrodynamic study during extracorporeal circulation in mock thoracic aorta. Artif Organs. 2007;31:880–6.PubMedGoogle Scholar
  47. 47.
    Minakawa M, Fukuda I, Igarashi T, Fukui K, Yanaoka H, Inamura T. Hydrodynamics of aortic cannulae during extracorporeal circulation in a mock aortic arch aneurysm model. Artif Organs. 2010;34:105–12.PubMedGoogle Scholar
  48. 48.
    Grooters RK, Ver Steeg DA, Stewart MJ, Thieman KC, Schneider RF. Echocardiographic comparison of the standard end-hole cannula, the soft-flow cannula, and the dispersion cannula during perfusion into the aortic arch. Ann Thorac Surg. 2003;75:1919–23.PubMedGoogle Scholar
  49. 49.
    Grooters RK, Thieman KC, Schneider RF, Nelson MG. Assessment of perfusion toward the aortic valve using the new dispersion aortic cannula during coronary artery bypass surgery. Tex Heart Inst J. 2000;27:361–5.PubMedGoogle Scholar
  50. 50.
    Fukuda I, Fujimori S, Daitoku K, Yanaoka H, Inamura T. Flow velocity and turbulence in the transverse aorta of a proximally directed aortic cannula: hydrodynamic study in a transparent model. Ann Thorac Surg. 2009;876:1866–71.Google Scholar
  51. 51.
    Yamana K, Ito T, Maekawa A, Yoshizumi T, Sunada M, Hoshino S. Atherosclerotic arch aneurysm operations with perfusion toward the aortic valve. Ann Thorac Surg. 2010;89:435–9.PubMedGoogle Scholar
  52. 52.
    White JK, Jagannath A, Titus J, Yoneyama R, Madsen J, Agnihotri AK. Funnel-tipped aortic cannula for reduction of atheroemboli. Ann Thorac Surg. 2009;88:551–7.PubMedGoogle Scholar
  53. 53.
    Gerdes A, Hanke T, Sievers HH. In vitro hydrodynamics of the Embol-X cannula. Perfusion. 2002;17:153–6.PubMedGoogle Scholar
  54. 54.
    Borger MA, Taylor RL, Weisel RD, Kulkarni G, Benaroia M, Rao V, et al. Decreased cerebral emboli during distal aortic arch cannulation: a randomized clinical trial. J Thorac Cardiovasc Surg. 1999;118:740–5.PubMedGoogle Scholar
  55. 55.
    Wada J, Komatsu S, Nakae S, Kazui T. A new cannulation method for isolated mitral valve surgery. “Apicoaortic-PA” cannulation. Thoraxchirugie. 1976;24:204–12.Google Scholar
  56. 56.
    Tanaka T, Kawamura T, Ohara K, Matsumoto M, Maeda H, Hiratsuka H. Transapical aortic perfusion with a double-barreled cannula. Ann Thorac Surg. 1978;25:209–14.PubMedGoogle Scholar
  57. 57.
    Yamamoto S, Hosoda Y, Yamasaki M, Ishikawa N, Fuchimoto K, Fukuda T. Transapical aortic cannulation for acute aortic dissection to prevent malperfusion and cerebral complications. Tex Heart Inst J. 2001;28:42–3.PubMedGoogle Scholar
  58. 58.
    Shiiya N, Yasuda K, Murashita T, Suto Y, Kanaoka T, Matsui Y, et al. Transapical aortic cannulation for hypothermic aortic operation through a left thoracotomy: an alternative to avoid retrograde arterial perfusion. J Thorac Cardiovasc Surg. 1997;113:1113–4.PubMedGoogle Scholar
  59. 59.
    Fukuda I, Yanaoka H, Inamura T, Minakawa M, Daitoku K, Suzuki Y. Experimental fluid dynamics of transventricular apical aortic cannulation. Artif Organs. 2010;34:222–4.PubMedGoogle Scholar
  60. 60.
    Matsushita A, Manabe S, Tabata M, Fukui T, Shimokawa T, Takanashi S. Efficacy and pitfalls of transapical cannulation for the repair of acute type A aortic dissection. Ann Thorac Surg. 2012;93:1905–9.PubMedGoogle Scholar
  61. 61.
    Price DL, Harris J. Cholesterol emboli in cerebral arteries as a complication of retrograde aortic perfusion during cardiac surgery. Neurology. 1970;20:1209–14.PubMedGoogle Scholar
  62. 62.
    Crooke GA, Schwartz CF, Ribakove GH, Ursomanno P, Gogoladze G, Culliford AT, et al. Retrograde arterial perfusion, not incision location, significantly increases the risk of stroke in reoperative mitral valve procedures. Ann Thorac Surg. 2010;89:723–9.PubMedGoogle Scholar
  63. 63.
    Ayyash B, Tranquilli M, Elefteriades JA. Femoral artery cannulation for thoracic aortic surgery: safe under transesophageal echocardiographic control. J Thorac Cardiovasc Surg. 2011;142:1478–81.PubMedGoogle Scholar
  64. 64.
    Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg. 1995;109:885–90.PubMedGoogle Scholar
  65. 65.
    Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF 3rd, Lytle BW, Gonzalez-Stawinski G, et al. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg. 2004;78:1274–84.PubMedGoogle Scholar
  66. 66.
    Strauch JT, Spielvogel D, Lauten A, Lansman SL, McMurtry K, Bodian CA, et al. Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement. Ann Thorac Surg. 2004;78:103–8.PubMedGoogle Scholar
  67. 67.
    Baribeau YR, Westbrook BM, Charlesworth DC, Maloney CT. Arterial inflow via an axillary artery graft for the severely atheromatous aorta. Ann Thorac Surg. 1991;66:33–7.Google Scholar
  68. 68.
    Schachner T, Vertacnik K, Laufer G, Bonatti J. Axillary artery cannulation in surgery of the ascending aorta and the aortic arch. Eur J Cardiothorac Surg. 2002;22:445–7.PubMedGoogle Scholar
  69. 69.
    Budde JM, Serna DL Jr, Osborne SC, Steele MA, Chen EP. Axillary cannulation for proximal aortic surgery is as safe in the emergent setting as in elective cases. Ann Thorac Surg. 2006;e2:2154–9.Google Scholar
  70. 70.
    Sinclair MC, Singer RL, Manley NJ, Montesano RM. Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls. Ann Thorac Surg. 2003;75:931–4.PubMedGoogle Scholar
  71. 71.
    Fukuda I, Unno H, Kaminishi Y. Strategies for preventing stroke after coronary artery bypass grafting [In Japanese]. Jpn J Thorac Cardiovasc Surg. 1998;46:38–45.PubMedGoogle Scholar
  72. 72.
    Etz CD, Plestis KA, Kari FA, Silovitz D, Bodian CA, Spielvogel D, et al. Axillary cannulation significantly improves survival and neurologic outcome after atherosclerotic aneurysm repair of the aortic root and ascending aorta. Ann Thorac Surg. 2008;86:441–6.PubMedGoogle Scholar
  73. 73.
    Gulbins H, Pritisanac A, Ennker J. Axillary versus femoral cannulation for aortic surgery: enough evidence for a general recommendation? Ann Thorac Surg. 2007;83:1219–24.PubMedGoogle Scholar
  74. 74.
    Ye J, Dai G, Ryner LN, Kozlowski P, Yang L, Summers R, et al. Unilateral antegrade cerebral perfusion through the right axillary artery provides uniform flow distribution to both hemispheres of the brain: a magnetic resonance and histopathological study in pigs. Circulation. 1999;100(19 suppl):II309–15.PubMedGoogle Scholar
  75. 75.
    Byrne JG, Fitzgerald DJ, Aranki SF. Simultaneous selective cerebral perfusion and systemic circulatory arrest through the right axillary artery for aortic surgery. J Card Surg. 1998;13:236–8.PubMedGoogle Scholar
  76. 76.
    Imanaka K, Kyo S, Tanabe H, Ohuchi H, Asano H, Yokote Y. Fatal intraoperative dissection of the innominate artery due to perfusion through the right axillary artery. J Thorac Cardiovasc Surg. 2000;120:405–6.PubMedGoogle Scholar
  77. 77.
    Minakawa M, Fukuda I, Inamura T, Yanaoka H, Fukui K, Daitoku K, et al. Hydrodynamic evaluation of axillary artery perfusion for normal and diseased aorta. Gen Thorac Cardiovasc Surg. 2008;56:215–21.PubMedGoogle Scholar
  78. 78.
    Kurisu K, Ochiai Y, Hisahara M, Tanaka K, Onzuka T, Tominaga R. Bilateral axillary arterial perfusion in surgery on thoracic aorta. Asian Cardiovasc Thorac Ann. 2006;14:145–9.PubMedGoogle Scholar
  79. 79.
    Banbury MK, Cosgrove DM 3rd. Arterial cannulation of the innominate artery. Ann Thorac Surg. 2000;69:957.PubMedGoogle Scholar
  80. 80.
    Urbanski PP, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A. Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg. 2006;132:1398–403.PubMedGoogle Scholar
  81. 81.
    Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Hypothermia, circulatory arrest, and cardiopulmonary bypass, Kirklin/Barratt-Boyes Cardioac Surgery p79. 3rd ed. Philadelphia: Churchill Livingstone; 2003.Google Scholar
  82. 82.
    Juvonen T, Zhang N, Wolfe D, Weisz DJ, Bodian CA, Shiang HH, et al. Retrograde cerebral perfusion enhances cerebral protection during prolonged hypothermic circulatory arrest: a study in a chronic porcine model. Ann Thorac Surg. 1998;66:38–50.PubMedGoogle Scholar
  83. 83.
    Reich DL, Uysal S, Ergin MA, Bodian CA, Hossain S, Griepp RB. Retrograde cerebral perfusion during thoracic aortic surgery and late neuropsychological dysfunction. Eur J Cardiothorac Surg. 2001;19:594–600.PubMedGoogle Scholar
  84. 84.
    Usui A, Miyata H, Ueda Y, Motomura N, Takamoto S. Risk-adjusted and case-matched comparative study between antegrade and retrograde cerebral perfusion during aortic arch surgery: based on the Japan Adult Cardiovascular Surgery Database : the Japan Cardiovascular Surgery Database Organization. Gen Thorac Cardiovasc Surg. 2012;60:132–9.PubMedGoogle Scholar
  85. 85.
    Zierer A, El-Sayed Ahmad A, Papadopoulos N, Moritz A, Diegeler A, Urbanski PP. Selective antegrade cerebral perfusion and mild (28°C–30°C) systemic hypothermic circulatory arrest for aortic arch replacement: Results from 1002 patients. J Thorac Cardiovasc Surg. 2012;144:1042–9.Google Scholar
  86. 86.
    Stern A, Tunick PA, Culliford AT, Lachmann J, Baumann FG, Kanchuger MS, et al. Protruding aortic arch atheromas: risk of stroke during heart surgery with and without aortic arch endarterectomy. Am Heart J. 1999;138:746–52.PubMedGoogle Scholar
  87. 87.
    Duda AM, Letwin LB, Sutter FP, Goldman SM. Does routine use of aortic ultrasonography decrease the stroke rate in coronary artery bypass surgery? J Vasc Surg. 1995;21:98–107.PubMedGoogle Scholar
  88. 88.
    Salenger R, Rodriquez E, Efird JT, Gouge CA, Trubiano P, Lundy EF. Clampless technique during coronary artery bypass grafting for proximal anastomoses in the hostile aorta. J Thorac Cardiovasc Surg. 2012 Jun 14. [Epub ahead of print].Google Scholar
  89. 89.
    Takami Y, Tajima K, Terazawa S, Okada N, Fujii K, Sakai Y. Safer aortic crossclamping during short-term moderate hypothermic circulatory arrest for cardiac surgery in patients with a bad ascending aorta. J Thorac Cardiovasc Surg. 2009;137:875–80.PubMedGoogle Scholar
  90. 90.
    Allison MA, Cheung P, Criqui MH, Langer RD, Wright CM. Mitral and aortic annular calcification are highly associated with systemic calcified atherosclerosis. Circulation. 2006;113:861–6.PubMedGoogle Scholar
  91. 91.
    Osranek M, Pilip A, Patel PR, Molisse T, Tunick PA, Kronzon I. Amounts of aortic atherosclerosis in patients with aortic stenosis as determined by transesophageal echocardiography. Am J Cardiol. 2009;103:713–7.PubMedGoogle Scholar
  92. 92.
    Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis. Ann Thorac Surg. 1996;61:149–52.PubMedGoogle Scholar
  93. 93.
    Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, et al. 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement: developed in collaboration with the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Mended Hearts, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Thorac Cardiovasc Surg. 2012;144:e29–84.PubMedGoogle Scholar
  94. 94.
    Czerny M, Weigang E, Sodeck G, Schmidli J, Antona C, Gelpi G, et al. Targeting landing zone 0 by total arch rerouting and TEVAR: midterm results of a transcontinental registry. Ann Thorac Surg. 2012;94:84–9.PubMedGoogle Scholar
  95. 95.
    Canaud L, Hireche K, Berthet JP, Branchereau P, Marty-Ané C, Alric P. Endovascular repair of aortic arch lesions in high-risk patients or after previous aortic surgery: midterm results. J Thorac Cardiovasc Surg. 2010;140:52–8.PubMedGoogle Scholar
  96. 96.
    Kawaguchi S, Yokoi Y, Shimazaki T, Koide K, Matsumoto M, Shigematsu H. Thoracic endovascular aneurysm repair in Japan: experience with fenestrated stent grafts in the treatment of distal arch aneurysms. J Vasc Surg. 2008;48:24S–9S.PubMedGoogle Scholar
  97. 97.
    Leshnower BG, Myung RJ, Thourani VH, Halkos ME, Kilgo PD, Puskas JD, et al. Hemiarch replacement at 28°C: an analysis of mild and moderate hypothermia in 500 patients. Ann Thorac Surg. 2012;93:1910–5.PubMedGoogle Scholar
  98. 98.
    Zierer A, Detho F, Dzemali O, Aybek T, Moritz A, Bakhtiary F. Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients. Ann Thorac Surg. 2011;91:1868–73.PubMedGoogle Scholar
  99. 99.
    Toyama M, Matsumura Y, Tamenishi A, Okamoto H. Safety of mild hypothermic circulatory arrest with selective cerebral perfusion. Asian Cardiovasc Thorac Ann. 2009;17:500–4.PubMedGoogle Scholar
  100. 100.
    Minakawa M, Fukuda I, Yamauchi S, Watanabe K, Kawamura T, Taniguchi S, et al. Early and long-term outcome of total arch replacement using selective cerebral perfusion. Ann Thorac Surg. 2010;90:72–7.PubMedGoogle Scholar
  101. 101.
    Leshnower BG, Myung RJ, Kilgo PD, Vassiliades TA, Vega JD, Thourani VH, et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg. 2010;90:547–54.PubMedGoogle Scholar
  102. 102.
    Safi HJ, Miller CC 3rd, Lee TY, Estrera AL. Repair of ascending and transverse aortic arch. J Thorac Cardiovasc Surg. 2011;142:630–3.PubMedGoogle Scholar
  103. 103.
    Ogino H, Sasaki H, Minatoya K, Matsuda H, Tanaka H, Watanuki H, et al. Evolving arch surgery using integrated antegrade selective cerebral perfusion: impact of axillary artery perfusion. J Thorac Cardiovasc Surg. 2008;136:641–8.PubMedGoogle Scholar
  104. 104.
    Patel HJ, Nguyen C, Diener AC, Passow MC, Salata D, Deeb GM. Open arch reconstruction in the endovascular era: analysis of 721 patients over 17 years. J Thorac Cardiovasc Surg. 2011;141:1417–23.PubMedGoogle Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2013

Authors and Affiliations

  • Ikuo Fukuda
    • 1
  • Kazuyuki Daitoku
    • 1
  • Masahito Minakawa
    • 1
  • Wakako Fukuda
    • 1
  1. 1.Department of Thoracic and Cardiovascular SurgeryHirosaki University Graduate School of MedicineHrosakiJapan

Personalised recommendations