THE ATHEROSCLEROTIC ASCENDING AORTA AND TRANSVERSE ARCH - A NEW TECHNIQUE TO PREVENT CEREBRAL INJURY DURING BYPASS - EXPERIENCE WITH 13 PATIENTS

Calcification of the ascending aorta and transverse arch significantly increases morbidity and may compromise the completeness of cardiac su rgical procedures. Several stratagems have been suggested to reduce th e risk, but for some patients this finding is still associated with a devastating outcome, irrespective of the technique employed. Thirteen patients (7 men and 6 women with a mean age of 66 years) with extensiv e calcification in the ascending aorta and transverse arch underwent c ardiopulmonary bypass (CFB). The presence of calcification was known p rior to CPB in 12 patients and noted after cross-clamping of the aorta in 1 patient. Special techniques for cannulation of the ascending aor ta or arch were undertaken in 12 patients; 1 patient required groin ca nnulation. In 12 patients CPB with gradual core cooling to 18 degrees C was done, during which time no manipulation of the aorta was allowed . Circulatory arrest was then initiated for 3.5 to 12 minutes. The aor ta was opened widely during this time to remove ulcerated plaques and friable debris, and to locate a safe place for aortic occlusion. All p atients recovered without neurological complications. In 1 patient, in whom occipital lobe infarcts developed, calcification was discovered after the aorta had been cross-clamped and necessitated subsequent end arterectomy of the ascending aorta and transverse arch. It is recommen ded that this hazardous finding be treated as follows: (1) selected ca nnulation of the ascending aorta or transverse arch with a long cannul a so that its tip is distal to the left subclavian artery; (2) profoun d core cooling and circulatory arrest; (3) visual inspection of the ao rta with removal of hazardous debris and preparation of a site for aor tic occlusion; and (4) consideration given to doing the entire procedu re with crossclamping because of the local aortic condition.