Aortic aneurysm after patch aortoplasty for coarctation in childhood

In 2 patients who had previously undergone patch aortoplasty for repair of coarctation of the aorta (CoA), progressive aneurysmal dilatation of the aorta developed at the site of the repair. Both patients underwent operative resection of the aneurysm.     

Pseudoaneurysm and aortobronchial fistula after aortic coarctation repair by patch aortoplasty

Pseudoaneurysm and aortobronchial fistula are very rare complications of aortic coarctation repair by means of patch aortoplasty, and are usually fatal if not treated surgically. A 26-year-old man with recent-onset massive hemoptysis had undergone aortic coarctation repair by means of Dacron patch aortoplasty at the age of 10 in our hospital. Computed tomography of the chest showed a descending aortic pseudoaneurysm. Left heart bypass was used for distal perfusion while the patient underwent graft interposition. Lung parenchyma around the fistula was repaired, and the patient was discharged after an uneventful postoperative course. When hemoptysis occurs in a patient with a history of thoracic aortic surgery, aortobronchial fistula should be suspected. Close follow-up is mandatory for patients who have undergone coarctation repair.     

Aortic aneurysm after patch aortoplasty repair of coarctation: a prospective analysis of prevalence, screening tests and risks

Twenty-nine children were evaluated prospectively for the presence of an aortic aneurysm at the repair site 1 to 19 years after patch aortoplasty repair of coarctation of the aorta. In each child, noninvasive evaluation included a chest X-ray film, computed tomography of the chest and two-dimensional echocardiography. The presence and size of an aortic aneurysm were determined quantitatively by measuring the ratio of the diameter of the thoracic aorta at the repair site to the diameter of the aorta at the diaphragm (aortic ratio). An aortic ratio of greater than or equal to 1.5 was judged abnormal and was shown to be significantly greater than the aortic ratio of a normal control group. An aortogram was obtained in each child if any noninvasive screening test was found to be abnormal. As assessed by the aortogram, the prevalence of aortic aneurysm was 24% in this patient group. The sensitivity of echocardiography and chest computed tomography for detecting an aneurysm was 71% and 66%, and the specificity 76% and 85%, respectively. The chest X-ray film was 100% sensitive and 68% specific in determining the presence of an aneurysm. Although the data are not statistically significant, they suggest that children undergoing patch aortoplasty as the primary procedure (rather than a reoperation after earlier resection), and children in whom a Dacron patch is utilized may be at increased risk for aneurysm formation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta.

OBJECTIVES. This study was undertaken to evaluate the progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta. BACKGROUND. Previous studies demonstrated a 5% to 25% incidence rate of repair site aneurysm 3 to 18 years after patch aortoplasty repair of coarctation. The natural history of aneurysmal progression in this disease entity has not previously been examined. METHODS. Twenty-nine patients were identified 5.6 +/- 1 years (mean +/- SE) postoperatively and classified into two groups: Group A, aneurysm (n = 7); Group B, no aneurysm (n = 22). The presence of an aneurysm was defined angiographically as a ratio of the repair site diameter to diaphragmatic aortic diameter (aortic ratio) greater than or equal to 1.5. A 23% prevalence (7 of 29) of aortic aneurysm was identified. One patient in Group A underwent semiemergency aneurysmectomy and two patients in Group B were lost to follow-up. The remaining 26 patients were reevaluated 3 to 5 years later by clinical examination and chest radiography. Aortograms were performed in all patients with suspected aneurysm formation or progression. RESULTS. Five of six patients in Group a demonstrated progressive aneurysmal dilation documented by an increase in aortic ratio from 1.64 +/- 0.06 to 2.04 +/- 0.2 (p = 0.03) and an increase in absolute aneurysm diameter from 2.5 +/- 0.3 to 3.6 +/- 0.5 cm (p = 0.006). Only 1 of 20 patients in Group B had evidence of new aneurysmal dilation (p less than 0.05 vs. Group A). Four patients in Group A have undergone elective aneurysmectomy, with equal distribution of true and pseudoaneurysms by pathologic examination. CONCLUSIONS. Aortic aneurysm formation is common after patch aortoplasty repair of coarctation of the aorta. The majority of patients with an aortic ratio greater than or equal to 1.5 will show significant progressive aneurysmal dilation within 3 to 5 years.     

Stress testing for comparison of synthetic patch aortoplasty with resection and end to end anastomosis for repair of coarctation in childhood

Excellent clinical results have been achieved by both resection with end to end anastomosis and synthetic patch aortoplasty for the repair of coarctation of the aorta in older children. Increasing experience with exercise stress testing in the postoperative evaluation of patients with coarctation has allowed the discovery of less obvious differences between the two procedures. To evaluate these differences further, the stress tests of 50 postoperative patients who underwent coarctation repair were reviewed: 26 patients with end to end anastomosis and 24 with synthetic patch aortoplasty. Twenty normal control subjects were similarly exercised. Systolic blood pressure in the arm and leg was evaluated before and after the test. Heart rate, electrocardiogram and arm blood pressure were monitored during the test. The mean arm systolic blood pressure was higher at all points of measurement in the patients who underwent repair by end to end anastomosis than in the group who underwent patch aortoplasty. These systolic pressure differences reached statistical significance only for standing arm blood pressure before exercise (p less than 0.05) and for supine arm systolic blood pressure immediately after exercise (p less than 0.01). There was no difference in arm-leg pressure gradient between the two study groups before exercise; however, after exercise the group with end to end anastomosis had significantly higher arm-leg pressure gradients (p less than 0.001). Significant differences between the two types of repair not apparent at rest were found immediately after exercise. The long-term prognostic importance of an exercise-induced arm-leg blood pressure gradient remains to be determined. However, exercise stress testing is sensitive in demonstrating these differences.     

Late aneurysms after patch aortoplasty for coarctation of the aorta in adults

Sixty-eight patch aortoplasties were performed for coarctation of the aorta (CoA) in adult patients from 1967 to 1978 in our hospital. The mortality was 1.5% and the immediate result of the surgical repair seemed good. Long-term follow-up of 2 to 14 years later revealed aneurysm formation at the repair area in 27% of the 62 patients for whom sufficient follow-up data are available. Two aneurysms had ruptured with a fatal outcome. Other repair methods used for coarctation in 106 patients were free from aneurysm complication. Thirteen patients with an aneurysm underwent reoperation without mortality. The etiology of these unexpected aneurysms is discussed.     

Cerebellar infarction secondary to subclavian aortoplasty repair for coarctation of the aorta

A five-year-old boy developed a left cerebellar infarction following repair of coarctation of the aorta by subclavian aortoplasty. At operation a large left vertebral artery had been ligated. If a large vertebral artery is encountered at repair of coarctation of the aorta then consideration should be given to a method of repair which does not sacrifice this vessel.     

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months.

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent). All patients underwent closure of the ductus arteriosus and patch angioplasty of the aorta to produce a luminal diameter of at least 16 mm. In addition, 9 of the 17 patients (53 percent) with a large shunt ventricular septal defect underwent pulmonary arterial banding. There was one hospital death 42 days after operation secondary to bowel perforation and sepsis. Hospitalization beyond 21 days postoperatively was always due to other unrepaired cardiac lesions. The three late deaths at 3, 9 and 18 months after operation were associated with additional major anomalies. Fourteen patients have had postoperative catheterization. No gradient was found across the site of coarctation repair, but one patient had a gradient between the left carotid and left subclavian arteries. Surgical repair of critical coarctation of the aorta in infants can safely be offered despite the presence of other cardiac anomalies.     

Aortic arch patch aortoplasty for Ortner's syndrome in the age of endovascular stented grafts

We present a case of hoarseness in a 68-year-old man with a post-traumatic saccular aortic arch aneurysm, effort dyspnea, and dysphonia. Oropharyngeal examination and flexible nasal endoscopy revealed left vocal fold palsy, with the left fold lying in the paramedian position. On account of these and other findings, we made the diagnosis of Ortner's syndrome. We treated the patient surgically by endoluminal repair with a Dacron patch. The postoperative course was uneventful. No additional procedure was necessary on the vocal folds, since he showed prompt postoperative speech improvement.We believe that an accurate evaluation should be made before switching a patient to endovascular treatment. Our case shows that careful preoperative planning, coupled with the most recent cerebral protection techniques, can enable a safe and straightforward surgical solution to a complex anatomic problem.     

Aortic dissection late after repair of congenital aortic coarctation

Aortic dissection is one of several complications that can be seen late after repair of aortic coarctation. We report an unusual presentation of this complication, and review the pertinent literature.     

Aortic coarctation and pregnancy

The association of coarctation of the aorta and pregnancy has been cause of concern among the various medical specialties involved in the care of patients with these conditions, as this cardiovascular abnormality is included in the list of disease potentially critical during pregnancy. The individually reported experience with this association has not been large, on account of the male predominance of this relatively rare congenital entity. The experience in the Internal Medicine Service of the "Concepción Palacios" Maternity Hospital of Caracas, Venezuela, between 1968 and 1985 is presented. Nine cases represented 2.9% of the congenital cardiovascular diseases, 0.84% of all cardiovascular diagnoses and 1.06 per 100.000 of all patients obstetrically attended during that period. In our experience, pregnancy is feasible in patients with coarctation, tolerance to gestation is generally good and fertility is not adversely affected, as well as prematurity and perinatal morbidity and mortality. The unique clinical situation of each patient, is to be nevertheless individually analyzed, especially in search for any other associated circulatory pathologic condition (s) which might render the patient more vulnerable than the average in the general group. The obstetric must prevail over the cardiologic criteria in the majority of cases, as to the mode of termination of pregnancy.     

Cardiac transplantation and aortic coarctation repair in severe heart failure

A 37-year-old man presented with severe dilated cardiomyopathy secondary to occult aortic coarctation. He was successfully managed with combined orthotopic heart transplantation and aortic coarctation repair.     

Aortic coarctation treated with bypass graft in adolescence and implantation of intravascular stent 12 years later--a case report

A case of a 26-year-old female with aortic coarctation and Recklinghausen disease is presented. At the age of 14 years the patient underwent thoracic aortic bypass grafting. Twelve years later she developed arterial hypertension. Spiral computerised tomography revealed patent graft and invasive hemodynamical measurements showed a gradient of 30 mmHg. The patient underwent successful intravascular stent implantation.