a 78-year - old female presented to another hospital with a complaint of recently aggravated exertional chest pain . the patient was diagnosed with unstable angina and exhibited triple - vessel disease upon undergoing coronary angiography , and she was subsequently referred to seoul national university bundang hospital for further management . surgical intervention was considered for the patient s coronary artery disease , and she therefore underwent preoperative computed tomography , which showed an ascending aortic aneurysm with a maximal diameter of 48 mm ( fig . since she had some risk factors , including old age and hypertension , and she was a suitable candidate for off - pump coronary artery bypass grafting ( cabg ) , we determined that aortic wrapping without cardiopulmonary bypass ( cpb ) would be a better option for her than replacement of the ascending aorta . we performed uneventful off - pump cabg with a y - composite graft , using bilateral internal thoracic arteries . after the adventitial tissue around the ascending aorta was fully mobilized , the ascending aorta was encircled from the innominate artery to the aortic root with a longitudinally divided , 32-mm hemashield vascular graft ( maquet holding gmbh & co , rastatt , germany ) . multiple bootstraps were evenly positioned along both edges using an interrupted mattress suture of 3/0 polypropylene ( fig . 2a , b ) . under permissive hypotension ( systolic blood pressure < 70 mmhg ) we then tied the straps with a teflon - pledget buttress placed inside the graft , preventing an incidental cut - through of the aorta . intraoperative trans - esophageal echocardiography showed normal cardiac function without aortic regurgitation . the patient s postoperative course was uneventful , and she was discharged on the 11th postoperative day without any complications . postoperative computed tomography was performed six months after the operation , showing a normally sized ascending aorta with mild inward folding of the intima ( fig . ascending aortic aneurysms are one of the most common findings in patients undergoing cardiac surgery , and they usually require surgical treatment along with other concomitant cardiac procedures . as observed in our case , it is common for cardiac surgeons to encounter an ascending aortic aneurysm in patients undergoing cabg , or to determine that cabg should be performed in a patient undergoing treatment for an ascending aortic aneurysm . concomitant cabg may be performed in up to 30% of patients undergoing either ascending aortic or aortic arch surgeries , according to previous studies [ 14 ] . there are several treatment options for ascending aortic aneurysms , and replacement of the ascending aorta with a prosthetic vascular graft is the most common surgical procedure currently performed . this procedure offers good perioperative results , due to remarkable advancements in both cpb and surgical technique ; however , the hospital mortality and morbidity rates still remain high , ranging up to 10% . for these reasons , many cardiac surgeons have sought to use simple and safe surgical techniques when treating ascending aortic aneurysms along with concomitant cardiac procedures , especially in patients with multiple comorbidities in whom prolonged cpb and aortic cross - clamping time can not be tolerated [ 13 ] . wrapping of the ascending aorta , with or without aortoplasty , is an alternative surgical procedure that can be performed to treat ascending aortic aneurysms . it has several advantages over graft replacement , such as less bleeding , shorter cpb and aortic cross - clamping time , and lower rates of morbidity and mortality . recent studies demonstrated the safety and durability of ascending aorta wrapping based on medium - term and long - term follow - up data [ 13 ] . reported the longest follow - up results , and their data were promising ; no early or in - hospital mortality was reported , and , most importantly , they reported no significant increases in the diameter of the ascending aorta , the incidence of dissection , or the incidence of rupture during the follow - up period . moreover , a histologic examination found no evidence of infection , erosion , or invasion of the synthetic graft . off - pump surgery is likely to be indicated for patients with multiple comorbidities such as old age , difficulty in early mobilization , or chronic renal failure . in these situations , if patients have both coronary artery disease and an ascending aortic aneurysm requiring surgical intervention , wrapping of the ascending aorta may be a good option for patients who are suitable candidates for off - pump cabg . as presented in our case as well as in previous reports , wrapping of the ascending aorta may be performed in a simple manner using a prosthetic vascular graft , and it may be performed safely without cpb support . furthermore , this method is even simpler when the multiple bootstraps technique is used , because the surgeon may reduce the size of the ascending aorta by simply securing the bootstraps under permissive hypotension . therefore , we believe that this technique may be a good choice for many cardiac surgeons considering wrapping of the ascending aorta , and it may be especially promising for older patients with multiple comorbidities , in whom prolonged cpb and aortic cross - clamping time may increase mortality and morbidity . although favorable medium - term and long - term results of wrapping of the ascending aorta have been reported in the previous literature , some concerns about this technique still exist . reported the occurrence of an aortic root aneurysm and preliminary dissection a few years after wrapping of the ascending aorta . additionally , polvani et al .   reported a 7.5% rate of redilatation and showed that preoperative diameter was a significant risk factor for redilatation . based on their study , ascending aorta wrapping should not be considered if the aneurysm is primarily due to aortic pathology , if the internal diameter of the aneurysm is > 55 mm , if the patient has a connective tissue disorder such as marfan syndrome , or if the aneurysm has heavy calcification , atherosclerosis , or penetrating ulcers [ 24,7,8 ] . therefore , in order to optimize the long - term outcome , cardiac surgeons should implement strictly defined indications when considering this technique . moreover , in addition to the above counterindications , the choice of using this surgical technique may be a matter of surgical preference . we successfully performed wrapping of the ascending aorta using the multiple bootstraps technique for an ascending aortic aneurysm in a patient who underwent concomitant off - pump cabg . this type of off - pump aortic wrapping is technically simple and safe , and can therefore represent a good alternative to ascending aorta replacement in select patients with moderately dilated ascending aortic aneurysms . the size of the ascending aorta was not an absolute indication for surgery ; however , we think that it was reasonable to perform wrapping of the ascending aorta for a moderately dilated aneurysm since the patient required off - pump cabg and since the wrapping procedure has been reported to be safe . although the early outcome of the present case was satisfactory , long - term follow - up is warranted , particularly to address concerns about the inward folding of the intima .
ascending aortic aneurysms are usually treated with graft replacement under cardiopulmonary bypass . 
 however , if a candidate for off - pump coronary artery bypass grafting has an enlarged ascending aorta , surgeons may consider wrapping it without cardiopulmonary bypass . here , we report a 78-year - old female who underwent successful wrapping of the ascending aorta concomitant with off - pump coronary artery bypass grafting , using a new wrapping technique that involves multiple bootstraps .