Iatrogenic Aortic Root and Left Main Dissection in CABG Surgery: An Unconventional Fix

Could you explain this simple surgical technique of "carving an ellipse"

Thank you for this question. This technique can be used to bypass a circumferentially calcified vessel with a good lumen (i.e. a coronary artery not completely obliterated by plaque) and when the non-calcified part of the distal artery is too small to bypass. Using the angiogram to correlate where a reasonable lumen exists (or using epicardial ultrasound if one has it), use the 'Beaver blade' (used to first incise a coronary before performance of anastomosis), carve an small ellipse the size of what you would like the opening of the anastomosis to be; if one wishes, one can check with a 1 mm probe the retrograde and anterograde patency of the coronary (being very careful not to dissect a plaque) and anastomose the conduit to the artery. Sometimes if the native coronary is so calcified, it is hard to pass a needle through the wall, one can use a fine Ryder needle driver to crush the walls to break the calcium and more easily pass the needle. (Sounds scary but it works). I always put these patients on Plavix for at least 6 months and if worried 12 months. (150 mg Plavix 2-4 hours early post-op when bleeding stopped and then 75 mg daily) Hope this helps! Teresa

Dear Teresa, Thanks for your answer. Regards

Hello dear colleague,actually i have two questions. First i wanna be more sure about the carving ellipse technic.So when you are performing a such one you a wide opened arteriotomy??and your sutures will pass by the fully wall ?all over the suturing anastomosis?It is like an open partial endarterectomy?? Second i was surprised by the postop angio after a couple of months..where the Marginals of Circ. are still TIMI3 though an endarterectomy and retrograde dissection and occluded grafts ..SO how can you explain this??unusual??

Dear Dr. Ejbeh, thank you for your very good questions. Firstly the ‘carving ellipse’ technique is not even a partial endarterectomy. To my mind, an endarterectomy requires that the whole interior circumference of the intima and 2/3 of the media of a native coronary artery are removed from a short distance proximally and completely distally from the opening arteriotomy in order to place a graft in a completely obliterated coronary. The ‘’carving ellipse’ technique is just removing a small oval of calcified artery from the anterior surface of the coronary to be bypassed. After making a usual arteriotomy in the native coronary artery, (which may require some force), using a small very sharp blade such as a Beaver blade, carve first from one side in as best as possible a ‘half-moon shape’ and then the other side. It doesn’t always look like a perfect ellipse. The piece of calcified wall removed measures about 2mm wide by 3 mm long for an arterial conduit, and a bit larger for a vein. Taking out some of the calcified wall prevents ‘clam-shelling’ shut of the anastomosis. A conduit (vein, IMA, or radial) is much softer that the calcified walls and the anastomosis with the native coronary walls being so solid will not stay open unless there is a missing part of the wall. The sutures must pass fully through the wall otherwise may create a dissection plane in the native diseased artery. ‘Crushing’ some of the calcium wall with a fine Ryder driver in order to pass the needle, as mentioned above, is sometimes needed, but there is usually some soft area somewhere to sew through/to. With respect to your second question and the patent marginal arteries despite endarterectomy of M2, and occluded marginal grafts, this does indeed appear to be unusual. During the first cross-clamp, the second M1 bypass well as the endarterectomy of M2 was added to ‘try everything’ to correct the suspected aortic root dissection from the bad graft to M2. The only explanation I can think of is that when the vein to the mid LAD was added, this gave enough competitive flow down the natural coronary system including the Cx system and the bypasses to the Cx system may have not been needed. The heart prefers the natural route. If you compare the pre and post-op angios of the marginal system, M1 looks worse and M2 about the same. There is a lot we do not know about flow of the coronary system; perhaps the ~80% stenosis of M2 was not that bad. Bring on FFR, PET scan etc. to determine more accurately which vessels need to be bypassed! Thank you for this astute observation! Most sincerely, Teresa

Dear Dr Thereza, i so appreciate your reply..practically what i meant in partial endarterctomy is a very localized calcific shaving from the edges of the arteriomized artery in order to get a more suitable artery to complete anastomosis...actually i did some of that cases once i was facing a severe calcification..and if i have to push more i prefer a long arteriotomy and doing an open total endarterectomy(avoiding the avulsion effect)... The difference between what i was doing and your carving one is the risk of dissection ,in the former one,in case of friable residual athero material... Your explanation of the procedure was so clear and corresponded to my understanding... I will surely consider and let you know of it works... Thanks a lot...

Dear Dr. Ejbeh, Thank you for your very kind comments, I am so glad to make the technique understood, you made my day! Teresa