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Extraanatomic Ascending-to-Descending Aortic Bypass Graft for Recurrent, Diffuse Aortic Coarctation
Extraanatomic Ascending-to-Descending Aortic Bypass Graft for Recurrent, Diffuse Aortic Coarctation Yun Hee Chang, MD,1 Jae Young Lee, MD,2 Yang Min Kim, MD,3 Man Jong Baek, MD,1 Cheul Lee, MD,1 Won-Min Jo, MD,1 and Woong-Han Kim, MD,1 Kyungki-do, South Korea
Surgical correction of recurrent coarctation of the aorta presents a formidable technical challenge. If the lesion is diffuse or has long-segment aortic hypoplasia, it can be more difficult to manage. We present a successful case of repair using an extraanatomic bypass graft from the innominate artery to descending aorta. This technique can be an effective and easy approach for selected cases of complex or reoperative aortic obstruction.
The most common reason for reintervention after repair of aortic coarctation is recurrence of obstruction either at the site of previous repair or some distance from it. A variety of approaches and surgical techniques have been described for the management of recurrent coarctation. If the lesion is focal, balloon angioplasty with or without a stent is a very effective method of relieving the stenotic lesion. However, surgery is preferred whenever there is a long segment of aortic recoarctation or multiple-site stenosis. Such lesions have been managed by using anatomic repair and extraanatomic bypass grafting. Anatomic repair may be complicated by the need for extensive mobilization of the aorta, control of the collateral blood vessels, the possibility of parenchymal lung injury, damage to recurrent or phrenic nerves, chylothorax, and spinal cord ischemia.1 We describe one case of intractable recurrent coarctation that was successfully managed by means of extraanatomic bypass grafting through median sternotomy.
1 Division of Cardiovascular Surgery, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. 2 Division of Pediatric Cardiology, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. 3 Division of Diagnostic Radiology, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. Correspondence to: Woong-Han Kim, MD, Division of Cardiovascular Surgery, Sejong General Hospital, Pucheon, Kyungki-do, 91-121, South Korea, E-mail: [email protected]
Ann Vasc Surg 2004; 18: 601-603 DOI: 10.1007/s10016-004-0090-x Ó Annals of Vascular Surgery Inc. Published online: 30 July 2004
CASE REPORT A 4-year-old female presented with recurrent coarctation with arch and descending aorta hypoplasia. She was originally admitted at another institution as a neonate with diffuse aortic arch stenosis associated with focal multiple aneurismal formation, which was corrected at 40 days of age by means of slide aortoplasty via a left thoracotomy. However, recurrent coarctation of the distal arch developed, which was treated with balloon dilatation on four occasions. On admission to our unit she was asymptomatic, but on physical examination her arm-leg pressure gradient was 20 mmHg by blood pressure cuff with diminished lower extremity pulses. A grade 2/6 late systolic murmur was audible at the left sternal border, epigastrium, and lower back. The electrocardiogram showed left ventricular hypertrophy by voltage criteria and the chest X-ray film was normal. Cardiac echocardiography revealed severe aortic coarctation creating a systolic pressure gradient of 60 mmHg across the lesion plus the presence of arch anomaly. Magnetic resonance imaging (MRT) demonstrated severe stenosis of the distal arch extending into the proximal descending thoracic aorta and there were suspicions of double aortic arch having an atretic right arch (Fig. 1). At operation, partial cardiopulmonary bypass was established through a median sternotomy incision, with an arterial cannula in the ascending aorta and a single venous cannula in the right atrium. Moderate hypothermia was achieved. The heart was lifted, and the posterior pericardium was incised to expose the descending thoracic aorta. A cross-clamp was applied and a 12-mm polytetrafluoroethylene (Gore-tex, W.L. Gore & Associates, Flagstaff, AZ) tube graft was anastomosed end-toside using continuous 6-0 Gore-tex suture. After hemostasis had been achieved, the heart was returned to its anatomic position. The proximal anastomosis was fashioned end-to-side to the large innominate artery with 601
602 Case reports
Annals of Vascular Surgery
Fig. 1. Preoperative MRI demonstrating severe stenosis of the distal arch extending into the proximal descending thoracic aorta and suspicion of double aortic arch having an atretic right arch. Left right posterior oblique aspect; right posterior aspect.
Fig. 2. Postoperative three-dimensional tomographic scan showing a widely patent bypass graft without distortion or stenosis. Left anterior aspect; right left lateral aspect.
sufficient redundancy in the graft to allow for growth. The patient was then weaned from cardiopulmonary bypass, and the sternotomy was closed in a standard fashion. Postoperatively, we used sodium nitroprusside to prevent rebound hypertension for 48 hr. This operation and medical management resulted in relief of the arm-leg pressure gradient with no complications. The patient made a good recovery and was discharged on the 10th postoperative day. A follow-up computed tomography (CT) angiogram confirmed excellent flow in the femoral arteries and a patent extraanatomic graft with no evidence of distortion or stenosis (Fig. 2). Echocardiography showed complete restoration of normal left ventricle function within 4 months of the operation.
descending aorta. Anatomic repair is unattractive because of the amount of mobilization of what is usually a very friable aorta and the increased risk of spinal cord ischemia and paresis, increased incidence of recoarctation, and late aneurysm formation at the repair site.5 Also, this type of repair is difficult because of severe mediastinal scarring. In the presence of severe scarring and a long segment of recurrent stenosis, extra anatomic bypass conduit around the diseased segment can give good results because dangerous dissection and clamping within the scarred mediastinum are avoided.6 Since the exact technique for extraanatomic ascending-descending bypass graft was first reported by Powell et al.,6 several reports have described the successful outcomes of ascending aorta-to-descending aorta bypass grafting through thoracotomy or median sternotomy.7-12 There were no graft—related complications, such as thrombosis, infection, and false aneurysm formation, during follow-up periods.
DISCUSSION The rates of recurrent coarctation, when repaired in early infancy, have ranged from 3 to 10%.2 The known mechanisms for recoarctation are inadequate anastomotic growth, scarring and fibrosis around the anastomosis site, excessive tension on suture lines, insufficient resection of the long, narrow segment and incorrect fashioning of prosthetic or subclavian flap, and kinking of a graft. Although there are no symptoms, a recoarctation is considered significant if the gradient is >20 mmHg between arm and leg by blood pressure cuff with or without proximal systemic hypertension. In most cases of recoarctation, nonsurgical interventions are possible.3 However, these procedures are not feasible in coarctations that have long-segment or multiple stenosis.4 Various approaches have been reported in cases like these, including resection of the narrowed segment with direct reanastomosis, patch or subclavian artery aortoplasty, and extraanatomic bypass conduit between the aortic arch and
CONCLUSIONS The presence of dense fibrosis around the previous repair site, a long segment of stenosis, and poor collateral flow make resection and local angioplasty difficult and hazardous. Extraanatomic aortic bypass can be applied safely and simply in the case of complex, recurrent aortic stenosis with no significant complication. The use of cardiopulmonary bypass has the added attraction of avoiding the need to cross-clamp the aorta at normothermia, which has the concomitant risk of spinal cord ischemia, particularly if collateral circulation is not well developed.
Vol. 18, No. 5, 2004
REFERENCES 1. Beekman RH, Rocchini AP, Behrndt DM, et al. Reoperation for coarctation of the aorta. Am. J. Cardiol. 1981;48:11081114. 2. Koller M, Rothlin M, Senning A. Coarctation of the aorta: review of 362 operate patients. Long-term follow-up and assessment of prognostic variables. Eur. Heart J. 1987;8:670679. 3. Hartmann AF, Jr, Goldring D, Hernandez A, et al. Recurrent coarctation of the aorta after successful repair in infancy. Am. J. Cardiol. 1970;25:405-410. 4. Weber HS, Cyran SE. Initial results and clinical follow-up after balloon angioplasty for native coarctation. Am. J. Cardiol. 1999;84:113-116. 5. Grinda JM, Mace L, Dervanian P, et al. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann. Thorac. Surg. 1995;60:1299-1302. 6. Powell WR, Adams PR, Cooley DA. Repair of coarctation of the aorta associated with intracardiac repair. Tex. Heart Inst. J. 1983;10:409-413.
Case reports 603
7. Heinemann MK, Ziemer G, Wahlers T, et al. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur. J. Cardiothorac. Surg. 1997;11:169-175. 8. Barron DJ, Lamb RK, Ogilvie BC, et al. Technique for extraanatomic bypass in complex aortic coarctation. Ann. Thorac. Surg. 1996;61:241-244. 9. Caspi J, Ilbawi MN, Milo S, et al. Alternative techniques for surgical management of recoarctation. Eur. J. Cardiothorac. Surg. 1997;12:116-119. 10. Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann. Thorac. Surg. 2000; 70:31-37. 11. Kanter KR, Erez E, Williams WH, et al. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J. Thorac. Cardiovasc. Surg. 2000;120: 885-890. 12. Connolly HM, Schaff HV, Izhar U, et al. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;104:1-133.
Surgical correction of recurrent coarctation of the aorta presents a formidable technical challenge. If the lesion is diffuse or has long-segment aortic hypoplasia, it can be more difficult to manage. We present a successful case of repair using an extraanatomic bypass graft from the innominate artery to descending aorta. This technique can be an effective and easy approach for selected cases of complex or reoperative aortic obstruction.
The most common reason for reintervention after repair of aortic coarctation is recurrence of obstruction either at the site of previous repair or some distance from it. A variety of approaches and surgical techniques have been described for the management of recurrent coarctation. If the lesion is focal, balloon angioplasty with or without a stent is a very effective method of relieving the stenotic lesion. However, surgery is preferred whenever there is a long segment of aortic recoarctation or multiple-site stenosis. Such lesions have been managed by using anatomic repair and extraanatomic bypass grafting. Anatomic repair may be complicated by the need for extensive mobilization of the aorta, control of the collateral blood vessels, the possibility of parenchymal lung injury, damage to recurrent or phrenic nerves, chylothorax, and spinal cord ischemia.1 We describe one case of intractable recurrent coarctation that was successfully managed by means of extraanatomic bypass grafting through median sternotomy.
1 Division of Cardiovascular Surgery, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. 2 Division of Pediatric Cardiology, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. 3 Division of Diagnostic Radiology, Sejong General Hospital, Pucheon, Kyungki-do, South Korea. Correspondence to: Woong-Han Kim, MD, Division of Cardiovascular Surgery, Sejong General Hospital, Pucheon, Kyungki-do, 91-121, South Korea, E-mail: [email protected]
Ann Vasc Surg 2004; 18: 601-603 DOI: 10.1007/s10016-004-0090-x Ó Annals of Vascular Surgery Inc. Published online: 30 July 2004
CASE REPORT A 4-year-old female presented with recurrent coarctation with arch and descending aorta hypoplasia. She was originally admitted at another institution as a neonate with diffuse aortic arch stenosis associated with focal multiple aneurismal formation, which was corrected at 40 days of age by means of slide aortoplasty via a left thoracotomy. However, recurrent coarctation of the distal arch developed, which was treated with balloon dilatation on four occasions. On admission to our unit she was asymptomatic, but on physical examination her arm-leg pressure gradient was 20 mmHg by blood pressure cuff with diminished lower extremity pulses. A grade 2/6 late systolic murmur was audible at the left sternal border, epigastrium, and lower back. The electrocardiogram showed left ventricular hypertrophy by voltage criteria and the chest X-ray film was normal. Cardiac echocardiography revealed severe aortic coarctation creating a systolic pressure gradient of 60 mmHg across the lesion plus the presence of arch anomaly. Magnetic resonance imaging (MRT) demonstrated severe stenosis of the distal arch extending into the proximal descending thoracic aorta and there were suspicions of double aortic arch having an atretic right arch (Fig. 1). At operation, partial cardiopulmonary bypass was established through a median sternotomy incision, with an arterial cannula in the ascending aorta and a single venous cannula in the right atrium. Moderate hypothermia was achieved. The heart was lifted, and the posterior pericardium was incised to expose the descending thoracic aorta. A cross-clamp was applied and a 12-mm polytetrafluoroethylene (Gore-tex, W.L. Gore & Associates, Flagstaff, AZ) tube graft was anastomosed end-toside using continuous 6-0 Gore-tex suture. After hemostasis had been achieved, the heart was returned to its anatomic position. The proximal anastomosis was fashioned end-to-side to the large innominate artery with 601
602 Case reports
Annals of Vascular Surgery
Fig. 1. Preoperative MRI demonstrating severe stenosis of the distal arch extending into the proximal descending thoracic aorta and suspicion of double aortic arch having an atretic right arch. Left right posterior oblique aspect; right posterior aspect.
Fig. 2. Postoperative three-dimensional tomographic scan showing a widely patent bypass graft without distortion or stenosis. Left anterior aspect; right left lateral aspect.
sufficient redundancy in the graft to allow for growth. The patient was then weaned from cardiopulmonary bypass, and the sternotomy was closed in a standard fashion. Postoperatively, we used sodium nitroprusside to prevent rebound hypertension for 48 hr. This operation and medical management resulted in relief of the arm-leg pressure gradient with no complications. The patient made a good recovery and was discharged on the 10th postoperative day. A follow-up computed tomography (CT) angiogram confirmed excellent flow in the femoral arteries and a patent extraanatomic graft with no evidence of distortion or stenosis (Fig. 2). Echocardiography showed complete restoration of normal left ventricle function within 4 months of the operation.
descending aorta. Anatomic repair is unattractive because of the amount of mobilization of what is usually a very friable aorta and the increased risk of spinal cord ischemia and paresis, increased incidence of recoarctation, and late aneurysm formation at the repair site.5 Also, this type of repair is difficult because of severe mediastinal scarring. In the presence of severe scarring and a long segment of recurrent stenosis, extra anatomic bypass conduit around the diseased segment can give good results because dangerous dissection and clamping within the scarred mediastinum are avoided.6 Since the exact technique for extraanatomic ascending-descending bypass graft was first reported by Powell et al.,6 several reports have described the successful outcomes of ascending aorta-to-descending aorta bypass grafting through thoracotomy or median sternotomy.7-12 There were no graft—related complications, such as thrombosis, infection, and false aneurysm formation, during follow-up periods.
DISCUSSION The rates of recurrent coarctation, when repaired in early infancy, have ranged from 3 to 10%.2 The known mechanisms for recoarctation are inadequate anastomotic growth, scarring and fibrosis around the anastomosis site, excessive tension on suture lines, insufficient resection of the long, narrow segment and incorrect fashioning of prosthetic or subclavian flap, and kinking of a graft. Although there are no symptoms, a recoarctation is considered significant if the gradient is >20 mmHg between arm and leg by blood pressure cuff with or without proximal systemic hypertension. In most cases of recoarctation, nonsurgical interventions are possible.3 However, these procedures are not feasible in coarctations that have long-segment or multiple stenosis.4 Various approaches have been reported in cases like these, including resection of the narrowed segment with direct reanastomosis, patch or subclavian artery aortoplasty, and extraanatomic bypass conduit between the aortic arch and
CONCLUSIONS The presence of dense fibrosis around the previous repair site, a long segment of stenosis, and poor collateral flow make resection and local angioplasty difficult and hazardous. Extraanatomic aortic bypass can be applied safely and simply in the case of complex, recurrent aortic stenosis with no significant complication. The use of cardiopulmonary bypass has the added attraction of avoiding the need to cross-clamp the aorta at normothermia, which has the concomitant risk of spinal cord ischemia, particularly if collateral circulation is not well developed.
Vol. 18, No. 5, 2004
REFERENCES 1. Beekman RH, Rocchini AP, Behrndt DM, et al. Reoperation for coarctation of the aorta. Am. J. Cardiol. 1981;48:11081114. 2. Koller M, Rothlin M, Senning A. Coarctation of the aorta: review of 362 operate patients. Long-term follow-up and assessment of prognostic variables. Eur. Heart J. 1987;8:670679. 3. Hartmann AF, Jr, Goldring D, Hernandez A, et al. Recurrent coarctation of the aorta after successful repair in infancy. Am. J. Cardiol. 1970;25:405-410. 4. Weber HS, Cyran SE. Initial results and clinical follow-up after balloon angioplasty for native coarctation. Am. J. Cardiol. 1999;84:113-116. 5. Grinda JM, Mace L, Dervanian P, et al. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann. Thorac. Surg. 1995;60:1299-1302. 6. Powell WR, Adams PR, Cooley DA. Repair of coarctation of the aorta associated with intracardiac repair. Tex. Heart Inst. J. 1983;10:409-413.
Case reports 603
7. Heinemann MK, Ziemer G, Wahlers T, et al. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur. J. Cardiothorac. Surg. 1997;11:169-175. 8. Barron DJ, Lamb RK, Ogilvie BC, et al. Technique for extraanatomic bypass in complex aortic coarctation. Ann. Thorac. Surg. 1996;61:241-244. 9. Caspi J, Ilbawi MN, Milo S, et al. Alternative techniques for surgical management of recoarctation. Eur. J. Cardiothorac. Surg. 1997;12:116-119. 10. Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann. Thorac. Surg. 2000; 70:31-37. 11. Kanter KR, Erez E, Williams WH, et al. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J. Thorac. Cardiovasc. Surg. 2000;120: 885-890. 12. Connolly HM, Schaff HV, Izhar U, et al. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;104:1-133.