CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 117 The effect of single aortic cross-clamp technique versus multiple clamp technique on postoperative stroke in octogenarians undergoing coronary artery bypass grafting Esra Erturk Tekin, Mehmet Balli, Mehmet Ali Yesiltas, Ayhan Uysal Abstract Aim: In this study, we aimed to investigate the effect of the single aortic cross-clamp technique (SCT) (aortic cross-clamp only) versus the multiple-clamp technique (MCT) (aortic cross-clamp + side-biting clamp) on postoperative stroke in octogenarians undergoing coronary artery bypass grafting (CABG). Methods: A total of 171 patients aged 80 years and older who underwent isolated CABG were retrospectively analysed. The patients were divided into two groups according to the technique used during surgery: group 1 (n = 88) received the SCT, and group 2 (n = 83) received the MCT. Postoperative stroke was evaluated. Results: Of the patients, 127 were men and 44 were women. The mean age was 83.05 ± 8.81 years in group 1 and 82.14 ± 8.92 years in group 2. There was no statistically significant difference in the rate of postoperative stroke between the two techniques (p > 0.05). Conclusion: Postoperative stroke in octogenarians may result from not only the cross-clamp technique used but also several other factors. We found that both techniques yielded similar outcomes. Keywords: octogenarians, aortic clamping, stroke, coronary artery bypass grafting Submitted 4/12/20; accepted 14/9/21 Published online 11/10/21 Cardiovasc J Afr 2022; 33: 117–121 www.cvja.co.za DOI: 10.5830/CVJA-2021-047 Over the last couple of decades, coronary artery bypass grafting (CABG) has been increasingly performed in octogenarians as the population ages.1 The incidence of cerebrovascular events following surgical coronary revascularisation ranges between one and 2.5%, which is remarkable.2 This proportion seems to be three-fold higher in elderly individuals.3 Irrespective of the age of the patient, neurological events dramatically increase mortality and morbidity rates after CABG. Ischaemic stroke following CABG is a multifactorial disease. The main predictor of peri-operative stroke is previous stroke or transient ischaemic attack and cerebral thromboembolism originating from the aorta, aortic branches or the heart itself, most frequently resulting from micro- and macro-embolism if it is associated with the cardiopulmonary bypass (CPB) procedure.3 Aortic manipulation and cross-clamping during CABG have been thought to play a critical role in the mechanism of embolism formation in patients with atherosclerosis of the ascending aorta.4 In the technique described by Salerno,5 distal and proximal anastomoses are constructed during a single period of total aortic occlusion, reducing the risk of embolism during aortic manipulation. However, the single aortic cross-clamp technique (SCT) is associated with prolonged cross-clamping, increasing the risk of cardiac and cerebral air or particle embolisation.6 In the literature, while the importance has been emphasised of identifying and understanding pre-operative risk factors and co-morbidities for neurological complications, the aortic crossclamp technique has been reported to be an important operative risk factor.7 Among the strategies developed to minimise trauma and therefore neurological complications in clamping the aorta, the benefits of using the single-clamp technique rather than the double-clamp technique, which requires the use of an aortic cross-clamp and side-bite clamp, have been supported.8,9 In this study, we hypothesised that intra-operative aortic manipulation would adversely affect elderly patients due to advanced aortic atherosclerosis. Therefore, we aimed to investigate the effect of SCT versus the multiple-clamp technique (MCT) on postoperative stroke in octogenarians undergoing isolated CABG. Methods This single-centre, retrospective study was conducted at the Department of Cardiovascular Surgery of Mersin City Training and Research Hospital between January 2016 and January 2020. Medical data of a total of 171 patients aged 80 years and older who underwent isolated CABG were retrospectively reviewed. The patients were divided into two groups according to the technique used during surgery: group 1 (n = 88) received the SCT and group 2 (n = 83) received the MCT. Department of Cardiovascular Surgery, Mersin City Training and Research Hospital, Mersin, Turkey Esra Erturk Tekin, MD, dresraer@yahoo.com Department of Cardiology, Mersin City Training and Research Hospital, Mersin, Turkey Mehmet Balli, MD Department of Cardiovascular Surgery, Bakirkoy Dr Sadi Konuk Training and Research Hospital, Istanbul, Turkey Mehmet Ali Yesiltas, MD Cardiovascular Surgery Clinic, Fırat University Medical Faculty, Elazığ, Turkey Ayhan Uysal, MD
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