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Treatment of aortic coarctation by axillofemoral bypass grafting in the high-risk patient
Treatment of Aortic Coarctation by Axillof emoral Bypass Grafting in the High-Risk Patient Cliff P. Connery, MD, James A. DeWeese, MD, Barry K. Eisenberg, MD, and Arthur J. Moss, MD Division of Cardiothoracic Surgery and Department of Medicine, School of Medicine and Dentistry, University of Rochester, Rochester, New York
Operative correction of coarctation of the aorta has been performed for 45 years. Reoperation for recurrent coarctation is necessary in as many as 5% to 10% of patients. Repair of recurrent coarctation carries an operative mortality of between 5% and 10%. Coarctation repair involves an increased risk in patients with advanced age, recurrent coarctation, congestive heart failure, and pulmonary disease. We report 3 cases where axillofemoral bypass has been used to treat high-risk patients with aortic coarctation. Two patients had had previous coarctation repair in addition to serious medical problems. Another patient had suffered three myocardial infarc-
tions and had disabling congestive heart failure. All patients had an immediate marked decrease in their preoperative peak systolic pressure gradient across the coarctation. Systemic hypertension and symptoms of congestive heart failure were improved in all patients. The length of follow-up was 15 months, 8.5 years, and 10.5 years. Reassessment with noninvasive vascular segmental pressure studies with and without an exercise component showed no recurrence of the pressure gradient. This procedure should be considered when treating coarctation of the aorta in the high-risk adult. (Ann Thorac Surg 1991;52:12814)
T
mize operative risk while at the same time providing correction of the gradient from the upper to the lower extremities. This technique has been used once in the repair of a 14-year-old boy with tandem coarctation of the thoracic and abdominal aorta with an intervening hypoplastic thoracic aorta [4].
he first successful operative correction of coarctation of the thoracic aorta was reported by Crafoord and Nylin [l],who performed resection and end-to-end anastomosis of coarctation in 2 patients in 1944. Gross [2] applied the techniques learned from his extensive animal research on thoracic coarctation when he performed a successful coarctation repair in 1945. Since then, other techniques for the treatment of coarctation have been described including interposition grafting, subclavian flap angioplasty, and intraluminal angioplasty. Although these procedures are more commonly performed in childhood and early adult life, there are a substantial number of older patients who require surgical repair of aortic coarctation, usually for a recurrence. A number of series have reported recurrent coarctation in from 5% to 50% of patients [3]. In general, recurrent coarctation repair can be performed effectively with acceptable mortality rates quoted at between 5% and 10%. We believe, however, that there is a subset of patients with either aortic coarctation or recurrent aortic coarctation who would fall into a much higher risk category for repair by an intrathoracic approach owing to advanced age and associated medical disorders such as severe congestive heart failure, pulmonary disease, and cerebrovascular disease. In 3 older patients with coarctation of the aorta and serious risk factors for perioperative mortality or complication, an axillofemoral bypass was performed to miniAccepted for publication J une 25, 1991 Address reprint requests to Dr Connery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, PO Box SURG, 601 Elmwood Ave, Rochester, NY 14642.
0 1991 by The Society of Thoracic Surgeons
Case Reports
Patient 1 The patient is a 70-year-old woman who had undergone coarctation repair at another hospital in 1949 at age 30 years. She initially did well, but in 1965 she required treatment for hypertension and diabetes. Subsequently she required treatment for supraventricular arrhythmias. In 1975 she had a cerebrovascular accident involving the vertebrobasilar system. In 1978 she was hospitalized with congestive heart failure. Cardiac catheterization revealed an 80-mm Hg gradient across her coarctation. Her symptoms of congestive failure progressed to New York Heart Association class 111. Her age of 59 years and her comorbidity (cerebrovascular disease, congestive failure, and diabetes) made her risk for thoracotomy prohibitive. Therefore a right axillofemoral bypass was performed in March 1979 using a preclotted 12-mm-diameter knitted Dacron graft. Her mean pressures intraoperatively were 80 mm Hg proximally and 77 mm Hg distally after the bypass. The patient did well. Her systolic blood pressure decreased from between 200 and 210 mm Hg on admission to between 150 and 180 mm Hg postoperatively on the same antihypertensive regimen. Over the next several years she required outpatient management of exertional 0003-4975/91/$3.50
1282
CONNERY ET AL AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
Patient 3
Table 1 . Noninvasive Vascular Studies Patient NO.
Pressure”
Time (mo)
Brachial
Thigh
Gradientb
PE Gradientb
108 104 15
102 170 149
111 169 161
0 1
0 0 0
1 2 3
0
Peak systolic pressure in millimeters of mercury. arm to thigh in millimeters of mercury. I‘E
=
Ann Thorac Surg 1991;52:12814
’Gradient from
postexercise
angina and mild congestive heart failure. Over the last 2 years she has suffered several myocardial infarctions and has required hospitalization on multiple occasions. At 10.5 years’ follow-up her graft was patent. Her most recent arm peak systolic pressure was 102 mm Hg with a systolic thigh pressure of 104 mm Hg (Table 1).
Patient 2 The patient is a 76-year-old man who was first found to have coarctation of the aorta in 1978 at the age of 65 years. Angiography at that time showed a lesion 2 cm distal to the left subclavian artery with a 100-mm Hg gradient across the aorta. He has a long history of hypertension and had his first of three myocardial infarctions in 1970. Between 1978 and 1980 the patient remained in a borderline compensated state with recurrent angina, dyspnea on exertion, and cardiomegaly. Ventricular ectopy developed, necessitating antiarrhythmic therapy, and the patient also had a conduction disturbance characterized by a left bundle-branch block and an intermittent high-grade atrioventricular block. In late 1980 the patient was admitted to our institution for further evaluation, which included noninvasive vascular studies. These demonstrated a right brachial pressure of 180 mm Hg and a right thigh peak systolic pressure of 88 mm Hg. Consideration was given to repairing his coarctation; however, it was believed that the patient’s age, history of multiple myocardial infarctions, and arrhythmias placed him at substantially increased risk for thoracotomy and repair of his coarctation. A right axillo-bifemoral bypass was performed using a preclotted 12-mm-diameter knitted Dacron graft. Postoperative angiography demonstrated preferential shunting of blood through the graft and a decrease in the gradient across the coarctation to 40 mm Hg. The patient’s upper extremity blood pressure subsequently decreased to 130170 mm Hg. One month later there was no segmental pressure gradient from the arm to the thigh. At the time of his most recent arterial examination in October 1989, there was no pressure gradient from upper to lower extremities at rest or after exercising on a treadmill for 5 minutes at 1% mph with a 10-degree grade. During the 9 years of follow-up the patient has done extremely well with well controlled hypertension and an improvement in his later noninvasive vascular studies (see Table 1).
This male patient had undergone an operation for his coarctation at age 16 years in 1949; the operation consisted of a division of the distal subclavian artery, which was turned down and anastomosed end-to-side to the aorta distal to the coarctation. In 1965 he had hypertension and stenosis of the anastomosis. He underwent thoracotomy, resection of the coarctation distal to the transverse arch, and replacement with an end-to-end Dacron graft. The patient was lost to follow-up until he returned in 1988 at age 55 years with hypertension and congestive heart failure. Despite aggressive medical management his symptoms progressed from New York Heart Association class I11 to class IV. Noninvasive vascular studies revealed a right brachial peak systolic pressure of 166 mm Hg and thigh peak systolic pressure of 114 mm Hg. Echocardiography revealed moderately to severely reduced left ventricular function. An aortogram demonstrated severe stenosis of the graft, with a 50-mm Hg gradient between the transverse arch and the descending thoracic aorta (Fig 1). It was recognized that repeat thoracic operation posed a serious risk in this patient. A right axillofemoral bypass graft was performed to decompress the upper extremities using a 10-mm-diameter Gore-Tex conduit. Intraoperative direct pressure measurement recorded 105 mm Hg proximally and 103 mm Hg peak systolic distally. His postoperative course was unremarkable. At follow-up 7 months later, the patient had returned to work full time and his hypertension was controlled by medication. A noninvasive postexercise arterial examination demonstrated no gradient from upper to lower extremities 15 months after operation (see Table 1).
Fig I . Aortogram of patient 3 dernonstratir~gseiiere steriosis of prcziioLis w a i t and recurrent coarctation.
Ann Thorac Surg 1991;52:1281-4
CONNERY ET AL
AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
1283
Comment The older population can present difficult problems when planning operation for aortic coarctation. Reoperation for restenosis of the aorta is a fairly common occurrence, as seen in 2 of the 3 patients described here. A recent review reported the incidence of reoperation for aortic coarctation to be from 5% to 10.2%. These rates vary with the type of repair, age at time of first procedure, and the duration of follow-up [3, 5, 61. Reoperation is generally believed to be indicated when there is a documented gradient of greater than 30 to 35 mm Hg at rest or exercise with evidence of recoarctation on angiography [3, 5, 71. Noninvasive vascular studies, particularly with an exercise component, are a sensitive indicator of recurrent or persistent coarctation [8]. Symptoms of recurrent coarctation include hypertension, exertional fatigue, severe headaches, epistaxis, congestive heart failure, and lower extremity claudication [5, 61. Findings at the time of recurrent coarctation repair may include dense mediastinal scarring, friability of the aorta, and less extensive collateral flow around the coarctation due to the previous surgical manipulation. With these findings at the time of operation it is not surprising that there are serious complications described after reoperation. These include anastomotic bleeding, recurrent laryngeal nerve paralysis, chylothorax [5, 61, phrenic nerve injury, and intrathoracic sepsis [3]. Presumably the risk of paraplegia secondary to spinal cord ischemia would be increased in the group of patients requiring reoperation; however, this complication is reported as rare [3]. Though some series report reoperation with no mortality [5, 91, operative mortality is generally believed to be between 5% and 10% [3]. A study by Sweeney and associates [5] described 53 patients who underwent reoperation over 23 years with no mortality and only 3 recorded complications. It should be noted, however, that the average age at reoperation in their study was only 18 years and congestive heart failure was present in only 3 of 53 patients preoperatively. Pollack and co-workers [9] reported a series demonstrating no mortality at reoperation, but their oldest patient was 21 years old. A variety of techniques for reoperation have been described to try to limit the above-noted morbidities. These methods include Dacron patch angioplasty, intrathoracic bypass around the coarctation [5, 101, resection with interposition graft, and resection with end-to-end anastomosis. Balloon dilatation angioplasty is described in the pediatric population [ll]. Late results after reoperation for aortic coarctation have shown that from 30% to 35% of patients have an upper extremity to lower extremity pressure gradient of more than 20 mm Hg [3]. Persistent hypertension has been documented in 20% of younger patients [9]. Axillofemoral grafts were first described by Blaisdell and Hall [12] in 1962 when they bypassed an abdominal aortic graft occlusion in a patient who had suffered an arrest upon induction of anesthesia. The patient survived the hospitalization and was ambulatory. As shown in our patients, axillofemoral bypass as a method of palliating
Fig 2 . Use of axillofemoral bypass grafting for coarctation.
recurrent coarctation avoids the potential intrathoracic complications described previously (Fig 2). In addition, the risk of perioperative death is presumably lessened in the patient with serious pulmonary disease and ventricular dysfunction by avoiding an intrathoracic approach. The procedure was well tolerated by the patients discussed, and follow-up data revealed excellent results concerning equalization of pressures in the upper and lower extremities and improved control of hypertension during the interval from 1 to 10.5 years postoperatively. Operation for coarctation has been performed now for 45 years. One can reasonably expect that the percentage of older patients with serious risk factors requiring consideration for operative correction will increase in the near future. Axillofemoral bypass is another technique that should be in the surgeon’s armamentarium when planning therapy in these patients at increased risk.
References 1. Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:34741. 2. Gross RE. Surgical correction for coarctation of the aorta. Surgery 1945;18:673-8. 3. Foster ED. Reoperation for aortic coarctation. Ann Thorac Surg 1984;38:81-9. 4. Sautter RD, Myers WO, Smullen WA, Griese GG, Ray JF. Tandem coarctations of thoracic and abdominal aorta with intervening hypoplastic thoracic aorta: treatment with unilateral axillofemoral graft. Ann Thorac Surg 1977;23:5824. 5. Sweeney MS, Walker WE, Duncan JM, Hallman GL, Livesay JJ, Cooley DA. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1985;40:4&9. 6. Beekman RH, Rocchini AP, Behrendt DM, Rosenthal A. Reoperation for coarctation of the aorta. Am J Cardiol 1981; 48: 1108-14.
1284
CONNERY ET AL AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
7. Presbitero P, Demarie D, Vilani M, et al. Long term results ( 1 5 3 0 years) of surgical repair of aortic coarctation. Br Heart J 1987;57462-7. 8. Connor TM. Evaluation of persistent coarctation of aorta after
surgery with blood pressure measurement and exercise testing. Am J Cardiol 1979;43:7P8. 9. Pollack P, Freed MD, Castaneda AR, Norwood WI. Reoperation for isthmic coarctation of the aorta: follow-up of 26 patients. Am J Cardiol 1983;51:1690-2.
Ann Thorac Surg 1991;52:12814
10. Edie RN, Janani J, Attai LA, Malm JR, Robinson G. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg 1975;20:55%66. 11. Kopf GS, Hellenbrand W, Kleinman C, Lister G, Talner N, Laks H. Repair of aortic coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41:42.530. 12. Blaisdell FW, Hall AD. Axillary-femoral artery bypass for lower extremity ischemia. Surgery 1963;54:56>8.
Operative correction of coarctation of the aorta has been performed for 45 years. Reoperation for recurrent coarctation is necessary in as many as 5% to 10% of patients. Repair of recurrent coarctation carries an operative mortality of between 5% and 10%. Coarctation repair involves an increased risk in patients with advanced age, recurrent coarctation, congestive heart failure, and pulmonary disease. We report 3 cases where axillofemoral bypass has been used to treat high-risk patients with aortic coarctation. Two patients had had previous coarctation repair in addition to serious medical problems. Another patient had suffered three myocardial infarc-
tions and had disabling congestive heart failure. All patients had an immediate marked decrease in their preoperative peak systolic pressure gradient across the coarctation. Systemic hypertension and symptoms of congestive heart failure were improved in all patients. The length of follow-up was 15 months, 8.5 years, and 10.5 years. Reassessment with noninvasive vascular segmental pressure studies with and without an exercise component showed no recurrence of the pressure gradient. This procedure should be considered when treating coarctation of the aorta in the high-risk adult. (Ann Thorac Surg 1991;52:12814)
T
mize operative risk while at the same time providing correction of the gradient from the upper to the lower extremities. This technique has been used once in the repair of a 14-year-old boy with tandem coarctation of the thoracic and abdominal aorta with an intervening hypoplastic thoracic aorta [4].
he first successful operative correction of coarctation of the thoracic aorta was reported by Crafoord and Nylin [l],who performed resection and end-to-end anastomosis of coarctation in 2 patients in 1944. Gross [2] applied the techniques learned from his extensive animal research on thoracic coarctation when he performed a successful coarctation repair in 1945. Since then, other techniques for the treatment of coarctation have been described including interposition grafting, subclavian flap angioplasty, and intraluminal angioplasty. Although these procedures are more commonly performed in childhood and early adult life, there are a substantial number of older patients who require surgical repair of aortic coarctation, usually for a recurrence. A number of series have reported recurrent coarctation in from 5% to 50% of patients [3]. In general, recurrent coarctation repair can be performed effectively with acceptable mortality rates quoted at between 5% and 10%. We believe, however, that there is a subset of patients with either aortic coarctation or recurrent aortic coarctation who would fall into a much higher risk category for repair by an intrathoracic approach owing to advanced age and associated medical disorders such as severe congestive heart failure, pulmonary disease, and cerebrovascular disease. In 3 older patients with coarctation of the aorta and serious risk factors for perioperative mortality or complication, an axillofemoral bypass was performed to miniAccepted for publication J une 25, 1991 Address reprint requests to Dr Connery, Division of Cardiothoracic Surgery, University of Rochester Medical Center, PO Box SURG, 601 Elmwood Ave, Rochester, NY 14642.
0 1991 by The Society of Thoracic Surgeons
Case Reports
Patient 1 The patient is a 70-year-old woman who had undergone coarctation repair at another hospital in 1949 at age 30 years. She initially did well, but in 1965 she required treatment for hypertension and diabetes. Subsequently she required treatment for supraventricular arrhythmias. In 1975 she had a cerebrovascular accident involving the vertebrobasilar system. In 1978 she was hospitalized with congestive heart failure. Cardiac catheterization revealed an 80-mm Hg gradient across her coarctation. Her symptoms of congestive failure progressed to New York Heart Association class 111. Her age of 59 years and her comorbidity (cerebrovascular disease, congestive failure, and diabetes) made her risk for thoracotomy prohibitive. Therefore a right axillofemoral bypass was performed in March 1979 using a preclotted 12-mm-diameter knitted Dacron graft. Her mean pressures intraoperatively were 80 mm Hg proximally and 77 mm Hg distally after the bypass. The patient did well. Her systolic blood pressure decreased from between 200 and 210 mm Hg on admission to between 150 and 180 mm Hg postoperatively on the same antihypertensive regimen. Over the next several years she required outpatient management of exertional 0003-4975/91/$3.50
1282
CONNERY ET AL AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
Patient 3
Table 1 . Noninvasive Vascular Studies Patient NO.
Pressure”
Time (mo)
Brachial
Thigh
Gradientb
PE Gradientb
108 104 15
102 170 149
111 169 161
0 1
0 0 0
1 2 3
0
Peak systolic pressure in millimeters of mercury. arm to thigh in millimeters of mercury. I‘E
=
Ann Thorac Surg 1991;52:12814
’Gradient from
postexercise
angina and mild congestive heart failure. Over the last 2 years she has suffered several myocardial infarctions and has required hospitalization on multiple occasions. At 10.5 years’ follow-up her graft was patent. Her most recent arm peak systolic pressure was 102 mm Hg with a systolic thigh pressure of 104 mm Hg (Table 1).
Patient 2 The patient is a 76-year-old man who was first found to have coarctation of the aorta in 1978 at the age of 65 years. Angiography at that time showed a lesion 2 cm distal to the left subclavian artery with a 100-mm Hg gradient across the aorta. He has a long history of hypertension and had his first of three myocardial infarctions in 1970. Between 1978 and 1980 the patient remained in a borderline compensated state with recurrent angina, dyspnea on exertion, and cardiomegaly. Ventricular ectopy developed, necessitating antiarrhythmic therapy, and the patient also had a conduction disturbance characterized by a left bundle-branch block and an intermittent high-grade atrioventricular block. In late 1980 the patient was admitted to our institution for further evaluation, which included noninvasive vascular studies. These demonstrated a right brachial pressure of 180 mm Hg and a right thigh peak systolic pressure of 88 mm Hg. Consideration was given to repairing his coarctation; however, it was believed that the patient’s age, history of multiple myocardial infarctions, and arrhythmias placed him at substantially increased risk for thoracotomy and repair of his coarctation. A right axillo-bifemoral bypass was performed using a preclotted 12-mm-diameter knitted Dacron graft. Postoperative angiography demonstrated preferential shunting of blood through the graft and a decrease in the gradient across the coarctation to 40 mm Hg. The patient’s upper extremity blood pressure subsequently decreased to 130170 mm Hg. One month later there was no segmental pressure gradient from the arm to the thigh. At the time of his most recent arterial examination in October 1989, there was no pressure gradient from upper to lower extremities at rest or after exercising on a treadmill for 5 minutes at 1% mph with a 10-degree grade. During the 9 years of follow-up the patient has done extremely well with well controlled hypertension and an improvement in his later noninvasive vascular studies (see Table 1).
This male patient had undergone an operation for his coarctation at age 16 years in 1949; the operation consisted of a division of the distal subclavian artery, which was turned down and anastomosed end-to-side to the aorta distal to the coarctation. In 1965 he had hypertension and stenosis of the anastomosis. He underwent thoracotomy, resection of the coarctation distal to the transverse arch, and replacement with an end-to-end Dacron graft. The patient was lost to follow-up until he returned in 1988 at age 55 years with hypertension and congestive heart failure. Despite aggressive medical management his symptoms progressed from New York Heart Association class I11 to class IV. Noninvasive vascular studies revealed a right brachial peak systolic pressure of 166 mm Hg and thigh peak systolic pressure of 114 mm Hg. Echocardiography revealed moderately to severely reduced left ventricular function. An aortogram demonstrated severe stenosis of the graft, with a 50-mm Hg gradient between the transverse arch and the descending thoracic aorta (Fig 1). It was recognized that repeat thoracic operation posed a serious risk in this patient. A right axillofemoral bypass graft was performed to decompress the upper extremities using a 10-mm-diameter Gore-Tex conduit. Intraoperative direct pressure measurement recorded 105 mm Hg proximally and 103 mm Hg peak systolic distally. His postoperative course was unremarkable. At follow-up 7 months later, the patient had returned to work full time and his hypertension was controlled by medication. A noninvasive postexercise arterial examination demonstrated no gradient from upper to lower extremities 15 months after operation (see Table 1).
Fig I . Aortogram of patient 3 dernonstratir~gseiiere steriosis of prcziioLis w a i t and recurrent coarctation.
Ann Thorac Surg 1991;52:1281-4
CONNERY ET AL
AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
1283
Comment The older population can present difficult problems when planning operation for aortic coarctation. Reoperation for restenosis of the aorta is a fairly common occurrence, as seen in 2 of the 3 patients described here. A recent review reported the incidence of reoperation for aortic coarctation to be from 5% to 10.2%. These rates vary with the type of repair, age at time of first procedure, and the duration of follow-up [3, 5, 61. Reoperation is generally believed to be indicated when there is a documented gradient of greater than 30 to 35 mm Hg at rest or exercise with evidence of recoarctation on angiography [3, 5, 71. Noninvasive vascular studies, particularly with an exercise component, are a sensitive indicator of recurrent or persistent coarctation [8]. Symptoms of recurrent coarctation include hypertension, exertional fatigue, severe headaches, epistaxis, congestive heart failure, and lower extremity claudication [5, 61. Findings at the time of recurrent coarctation repair may include dense mediastinal scarring, friability of the aorta, and less extensive collateral flow around the coarctation due to the previous surgical manipulation. With these findings at the time of operation it is not surprising that there are serious complications described after reoperation. These include anastomotic bleeding, recurrent laryngeal nerve paralysis, chylothorax [5, 61, phrenic nerve injury, and intrathoracic sepsis [3]. Presumably the risk of paraplegia secondary to spinal cord ischemia would be increased in the group of patients requiring reoperation; however, this complication is reported as rare [3]. Though some series report reoperation with no mortality [5, 91, operative mortality is generally believed to be between 5% and 10% [3]. A study by Sweeney and associates [5] described 53 patients who underwent reoperation over 23 years with no mortality and only 3 recorded complications. It should be noted, however, that the average age at reoperation in their study was only 18 years and congestive heart failure was present in only 3 of 53 patients preoperatively. Pollack and co-workers [9] reported a series demonstrating no mortality at reoperation, but their oldest patient was 21 years old. A variety of techniques for reoperation have been described to try to limit the above-noted morbidities. These methods include Dacron patch angioplasty, intrathoracic bypass around the coarctation [5, 101, resection with interposition graft, and resection with end-to-end anastomosis. Balloon dilatation angioplasty is described in the pediatric population [ll]. Late results after reoperation for aortic coarctation have shown that from 30% to 35% of patients have an upper extremity to lower extremity pressure gradient of more than 20 mm Hg [3]. Persistent hypertension has been documented in 20% of younger patients [9]. Axillofemoral grafts were first described by Blaisdell and Hall [12] in 1962 when they bypassed an abdominal aortic graft occlusion in a patient who had suffered an arrest upon induction of anesthesia. The patient survived the hospitalization and was ambulatory. As shown in our patients, axillofemoral bypass as a method of palliating
Fig 2 . Use of axillofemoral bypass grafting for coarctation.
recurrent coarctation avoids the potential intrathoracic complications described previously (Fig 2). In addition, the risk of perioperative death is presumably lessened in the patient with serious pulmonary disease and ventricular dysfunction by avoiding an intrathoracic approach. The procedure was well tolerated by the patients discussed, and follow-up data revealed excellent results concerning equalization of pressures in the upper and lower extremities and improved control of hypertension during the interval from 1 to 10.5 years postoperatively. Operation for coarctation has been performed now for 45 years. One can reasonably expect that the percentage of older patients with serious risk factors requiring consideration for operative correction will increase in the near future. Axillofemoral bypass is another technique that should be in the surgeon’s armamentarium when planning therapy in these patients at increased risk.
References 1. Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:34741. 2. Gross RE. Surgical correction for coarctation of the aorta. Surgery 1945;18:673-8. 3. Foster ED. Reoperation for aortic coarctation. Ann Thorac Surg 1984;38:81-9. 4. Sautter RD, Myers WO, Smullen WA, Griese GG, Ray JF. Tandem coarctations of thoracic and abdominal aorta with intervening hypoplastic thoracic aorta: treatment with unilateral axillofemoral graft. Ann Thorac Surg 1977;23:5824. 5. Sweeney MS, Walker WE, Duncan JM, Hallman GL, Livesay JJ, Cooley DA. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1985;40:4&9. 6. Beekman RH, Rocchini AP, Behrendt DM, Rosenthal A. Reoperation for coarctation of the aorta. Am J Cardiol 1981; 48: 1108-14.
1284
CONNERY ET AL AXILLOFEMORAL BYPASS FOR AORTIC COARCTATION
7. Presbitero P, Demarie D, Vilani M, et al. Long term results ( 1 5 3 0 years) of surgical repair of aortic coarctation. Br Heart J 1987;57462-7. 8. Connor TM. Evaluation of persistent coarctation of aorta after
surgery with blood pressure measurement and exercise testing. Am J Cardiol 1979;43:7P8. 9. Pollack P, Freed MD, Castaneda AR, Norwood WI. Reoperation for isthmic coarctation of the aorta: follow-up of 26 patients. Am J Cardiol 1983;51:1690-2.
Ann Thorac Surg 1991;52:12814
10. Edie RN, Janani J, Attai LA, Malm JR, Robinson G. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg 1975;20:55%66. 11. Kopf GS, Hellenbrand W, Kleinman C, Lister G, Talner N, Laks H. Repair of aortic coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41:42.530. 12. Blaisdell FW, Hall AD. Axillary-femoral artery bypass for lower extremity ischemia. Surgery 1963;54:56>8.