**4. Calcified aorta**

The atherosclerotic involvement of the ascending aorta presents technical challenge in patients undergoing CABG. The degree of calcification ranges from isolated plaques to total calcifica‐ tion which is known as porcelain aorta. The danger of applying cross clamp is associated with markedly increased incidence of cerebral or systemic embolism. The avoidance of multiple aortic manipulations is the key and strategy must be designed based on this principle.

Atherosclerotic disease of the ascending aorta is becoming an increasing problem and is important to understand the prevalence of this disease entity. Mills and Everson reported 2.0% of unclampable aorta in their CABG population of 1735 patients. [25] Other reports have indicated its occurrence between 2-5% [26, 27]. Goto et al reported in their 463 patients undergoing CABG reported stroke rate of 10.5% in patients with severe atherosclerosis compared with 1.8% in normal or near-normal control patients. [28] The challenges in such situation are to make the accurate diagnosis and operative strategy.
