The authors employed a modified CABG procedure to avoid cerebral infarction in cases of calcified ascending aorta. Among 348 cases of CABG surgery, we used the modified procedure in 14 cases (4%). The mean age was 66. Four patients had a history of previous stroke and one patient had arteriosclerosis obliterans. Our strategy is, (1) use femoral or aortic arch cannulation for cardiopulmonary bypass (CPB), (2) maximal use of in-situ arterial graft, (3) graft-coronary anastomosis under ventricular fibrillation (Vf) without aortic cross clamp, (4) proximal anastomosis of saphenous vein graft (SV), if used, was made at the arterial graft, otherwise direct anastomosis to the aorta was made under circulatory arrest. The internal thoracic artery (ITA) was used in 18 cases and the gastroepiploic artery (GEA) was used in 8 cases, SV was used in 4 cases. The mean Vf time was 48min and mean CPB time was 94min. The peak CPK was 805U and the peak CPK-MB was 52U. There was no significant difference between modified and conventional procedures in terms of operation time and myocardial protection. No cerebrovascular complication was noted with the modified procedure. In conclusion, the modified technique is safe for atherosclerotic-ascending aorta in CABG.

A 59-year-old man, who had received graft replacement for the “inflammatory” abdominal aortic aneurysm two years previously was admitted to our hospital because of preshock caused by intermittent intestinal hemorrhage. Gastrointestinal endoscopy revealed an ulcer at the 3rd portion of the duodenum. As aortoenteric fistula was diagnosed and he underwent an emergency operation. After initial axillo-bifemoral bypass grafting, the aortic graft was removed and the aortic stump was closed directly. The duodenal rent was closed by Albert-Lembert suture, He survived the operation and was discharged. We suggest that extra-anatomic bypass is safer than in situ graft replacement in patients with secondary aortoenteric fistula after operation for “inflammatory” abdominal aortic aneurysm, because adjacent organs adhere firmly to the proximal suture line in such cases.