*2.3.1 Position selection*

A considerable proportion of patients with coronary disease has ascending atherosclerosis. Many soft atherosclerotic plaques similar to "toothpastes" exist in the middle layer of ascending aorta, whereas obvious calcification can be identified by finger touch on the surface of aorta. Therefore, the plaques are prone to break and fall off after the application of side wall clamp and lead to organ embolism along with blood flow. In addition, except for the requirement of healthy aortic tissue at the puncture insertion point and anastomotic site, healthy tissue should also be selected between the two points as much as possible to avoid excessive bleeding due to atherosclerosis or calcification of the arterial wall between the two points, or plaque falling off due to extrusion.

**Figure 1.**

*Enclose device demonstration. (A) Needle puncture; (B) Enclose insertion; (C) Membrane unscrewed; (D) Upper jaw downward; (E) Circular knife cut; (F) Perforation; (G) Anastomosis.*

### *2.3.2 Avoid damage to Enclose membrane*

Most of the damage occurred in the process of aortic wall incision with circular knife and suturing. The aortic wall should be cut perpendicular to the connecting rod as much as possible to avoid cutting the diaphragm. When suturing, the needle should be carefully pressed against the inner wall of the aorta from internal to external, to avoid massive hemorrhage caused by deep penetration of Enclose diaphragm or vertical needle insertion. Slight injury of diaphragm may lead to increased bleeding risk in the operation area. In most cases, operations can be continued under the control of blood pressure and sufficient suction. If the diaphragm's damage is too serious, most of the surgeons will have to use other methods to avoid massive blood loss.

**261**

*Management of Ascending Aorta Calcification in Coronary Artery Bypass Grafting*

Although we use 2–0 polypropylene suture to reinforce the puncture points

We have met several cases where the Enclose membrane could not be opened and the equipment was replaced. It is considered to be related to the technology and process in the production process. Therefore, it is necessary to test whether the

Implantation and use of Enclose may also lead to injury, rupture and even aneurysm formation of the aortic wall. It may be due to the insertion of Enclose's lower jaw into the wall of ascending aorta, or due to the damage of aortic intima caused by overcompression, which is easy to form aneurysm when the blood pressure rises. Therefore, it is very important to control blood pressure during the operation and, at the same time, on the premise of no blood environment in the operation area, to loosen the knob as much as possible to reduce the excessive

It is often the case that the intimal dissection of the internal mammary artery (IMA) has to be replaced by the total vein coronary artery bypass grafting. Thus, Enclose was re-implanted after the injury of the IMA or when the flow of the IMA graft is poor. The distance between the suture and the punch hole should not be

membrane can open and close smoothly before each aortic implantation.

during the operation for the Enclose cases, there are still a few patients in intensive care unit (ICU) with pericardial drainage fluid increase sharply and in bright red color. This is found to be blood leakage at the puncture point during emergency thoracotomy and hemostasis. The secondary suture for reinforcement with 2–0 polypropylene and felt pad can effectively stop bleeding. The reason for bleeding may be attributable to the inaccurate suture during the process. When the blood pressure is stable without obvious bleeding under anesthesia, the huge postoperative blood pressure fluctuation may increase the arterial pressure and

*Application of Enclose: (A) the great saphenous vein; (B) aortic anastomosis.*

*DOI: http://dx.doi.org/10.5772/intechopen.91909*

*2.3.3 Puncture point reinforcement*

**Figure 2.**

lead to suture avulsion.

*2.3.4 Mechanical failure*

*2.3.5 Aortic wall injury*

pressure on the aortic wall.

*2.3.6 Re-implantation*

*Management of Ascending Aorta Calcification in Coronary Artery Bypass Grafting DOI: http://dx.doi.org/10.5772/intechopen.91909*

**Figure 2.** *Application of Enclose: (A) the great saphenous vein; (B) aortic anastomosis.*
