Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.     

Ascending-to-descending aortic bypass via posterior pericardium for complex coarctation of aorta

Abstract   We introduce our surgical experience in treating recurrent aortic coarctation or coarctation associated with intracardiac abnormalities, which is difficult to manage. Four patients underwent the operation with hypothermic cardiopulmonary bypass. During the surgery, the posterior pericardium was opened and the thoracic aorta was dissected and sidebiting clamped, and an end-to-side anastomosis of the artificial graft to the descending aorta was performed. The graft was passed in between the inferior vena cava and the inferior right pulmonary vein and posterior to the pericardium. After that, the aorta was clamped and intracardiac repair was finished. Then the proximal artificial graft was anastomosed to the right side of the ascending aorta with heart beating. All patients recovered smoothly. There was no early or late death, without bleeding or other complications after operation. Conclusion : "Complex coarctation" can be treated with ascending-to-descending aortic bypass via posterior pericardium and satisfied result can be achieved.     

Acute type A aortic dissection and coarctation of aortic isthmus

Acute type A aortic dissection and coarctation of the aorta is a rare associated disease. A case of two-stage repair is presented. Firstly the ascending aorta and the right hemi-arch was replaced using deep hypo-thermic circulatory arrest. Cardiopulmonary bypass was proximally instituted, in a patient with total aortic isthmus occlusion, using right axillary artery cannulation. Distally arterial perfusion was obtained cannulating the bilateral hypoplasic femoral arteries. Ten months later a left subclavian artery-descending thoracic aorta bypass was performed.     

One-stage repair with separated cardiopulmonary bypass for coarctation of the aorta with left aortic arch and right thoracic descending aorta

We treated a 7-day-old neonate with aortic coarctation, left aortic arch, right-side descending aorta, aberrant right subclavian artery, and outlet ventricular septal defect. Surgical one-stage repair consisting of coarctation repair by extended direct anastomosis, patch closure of the ventricular septal defect, and translocation of the right subclavian artery was performed under a separated (upper and lower body) perfusion with ascending and thoracic descending aortic cannulation. The postoperative course was complicated with massive chylous effusion, which was successfully treated by thoracic duct ligation.     

Hypothermic circulatory arrest through a left thoracotomy in a 12-year-old child with aortic coarctation

Surgical correction of adult complex aortic coarctation using hypothermic circulatory arrest often requires central cannulation to secure cerebral perfusion. It is not easy to place the cannula in the ascending aorta, however, especially in children undergoing surgery through a left thoracotomy. In a 12-year-old male with hypoplastic distal aortic arch, we placed an arterial cannula in the ascending aorta using the Seldinger puncture technique through the stenotic segment of the distal aortic arch. Replacement of the stenotic segment with a 20 mm-size Dacron graft was then routine. The ascending aorta was exposed only for the proximal anastomosis. The left subclavian artery was also reconstructed. This central cannulation technique is simple and is useful in repairing complex aortic coarctation.     

A novel technique of coronary revascularization in porcelain aorta: Report of two cases

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.     

Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results

BACKGROUND: We analyzed our 22 years of experience with extraanatomic bypass grafting for repair of aortic arch coarctation in adults. Results from early and midterm follow-up with clinical evaluation and magnetic resonance angiography are reported. METHODS: Between November 1979 and December 2001, 18 consecutive patients aged 18 to 61 years (mean, 31.8 +/- 13.3 years) underwent extraanatomic bypass grafting to repair coarctation of the aortic arch. Six patients (33.3%) had recoarctation after previous repair through a left thoracotomy, and 3 (16.7%) had associated cardiac diseases. The operative technique used in all patients was ascending aorta-to-descending thoracic aorta bypass with a polyethylene terephthalate fiber (Dacron) graft through a median sternotomy and posterior pericardial approach. RESULTS: Follow-up was completed in all patients, with a mean duration of 5.6 +/- 5.7 years (range, 12 months to 22 years). The follow-up interval exceeded 10 years in 5 patients. No neurologic complications, early or late mortality, late reoperations, or graft complications occurred. Six patients (33.3%) had mild hypertension. All patients were asymptomatic with patent Dacron grafts confirmed by echocardiography. Magnetic resonance angiography, performed in 15 (83.3%) patients, revealed that the Dacron grafts were still patent at a mean interval of 4.0 +/- 6.2 years (range, 5 days to 22 years) after repair. CONCLUSIONS: Extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic arch coarctation in adults is safe, with low morbidity and no mortality. The favorable midterm results indicate this technique is a safe and less invasive means of repairing aortic arch coarctation or recoarctation in adults.     

Single-stage repair of aortic coarctation with ventricular septal defect using isolated cerebral and myocardial perfusion.

OBJECTIVE: To avoid hypothermic circulatory arrest, we have repaired aortic coarctation with ventricular septal defect (VSD) in a one-stage procedure using an isolated cerebral and myocardial perfusion technique, and retrospectively compared this novel approach to the conventional two-stage approach. METHODS: Between October 1991 and February 1999, 24 infants, aged 4-137 days (median, 27 days) and weighing 1.7-4.3 kg (median, 3.0 kg), underwent the repair of aortic coarctation with VSD either in one (group I, n=11) or two stages (group II, n=13). In Group I, an arterial cannula for cardiopulmonary bypass was inserted into the ascending aorta in six patients with coarctation only, or into a polytetrafluoroethylene (PTFE) graft which was anastomosed to the innominate artery in the remaining five who had hypoplastic arches. A cross-clamp was placed between the innominate and left carotid arteries. The bypass flow was reduced to 30-50% of full flow at 28 degrees C, thereby maintaining a radial artery pressure of 30-45 mmHg. At this point, the aortic coarctation was repaired by an end-to-end arch anastomosis, while maintaining brain perfusion and with the heart still beating. In five patients with hypoplastic aortic arches, the innominate artery proximal to the graft was then secured down and the arch anastomosis was extended to the distal ascending aorta, while providing isolated cerebral perfusion and cardioplegic arrest. After arch reconstruction was performed, the clamp was moved onto the ascending aorta, and the VSD was closed with systemic perfusion. In contrast, for group II patients, coarctation repairs were performed through a posterolateral approach, and existing VSDs were closed as secondary procedures. RESULTS: The mean isolated cerebral and myocardial perfusion time for group I was 13 min (range, 7-20 min). The myocardial ischemic time did not differ between groups I and II (43+/-4 vs. 42+/-5 min, not significant). There were no hospital mortalities or neurological complications in either group, but one late death in each group. CONCLUSION: Single-stage repair of aortic coarctation with VSD does not increase myocardial ischemic time compared to the traditional two-stage approach. The isolated cerebral and myocardial perfusion technique may offer substantial brain and myocardial protection during aortic arch reconstruction.     

Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection

PURPOSE: We describe a modular stent graft for use in endovascular repair of aneurysms of the aortic arch. METHOD: Carotid-carotid and left carotid-subclavian bypass grafts are created surgically. Two large, fully stented grafts are inserted endoluminally. The proximal component is bifurcated, with a wide proximal trunk and two distal limbs, one long and narrow, the other short and wide. This component is inserted through the carotid artery and deployed with the trunk and short wide limb in the ascending thoracic aorta; the long narrow limb opens into the innominate artery. After delivery system removal and carotid artery repair, a distal component is inserted through a femoral approach to bridge the gap between the short, wide distal limb of the proximal component and the nondilated descending thoracic aorta. The result is a branched stent graft, implanted proximally into the ascending aorta and distally into the innominate artery and descending thoracic aorta. CONCLUSION: The system has been used successfully to treat a large wide-necked pseudoaneurysm of the aortic arch.     

Transpericardial extra-anatomic intrathoracic aortic bypass conduits in the management of coarctation of the aorta

Two varied cases of coarctation of the aorta are described, in which transpericardial ascending to descending thoracic aortic conduits were routed around the right atrium, utilizing deep hypothermic circulatory arrest. The approach was through a median sternotomy in two patients. The first case is a 52-year-old female who underwent combined aortic valve replacement for aortic stenosis and repair of aortic coarctation distal to the left subclavian artery. The second case was a fifth time reoperation in a 12-year-old girl with recurrent coarctating. Both patients remain well and asymptomatic.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Off-Pump Extraanatomic Bypass from the Ascending to the Descending Aorta for Re-Operation of Interrupted Aortic Arch in an Adolescent

Abstract   The appearance of re-stenosis after repair of an interrupted aortic arch may be a surgical challenge due to adhesions. Here, we describe an approach using off-pump coronary artery bypass grafting techniques to reach the descending aorta through a median sternotomy in a patient with aortic arch stenosis after conduit repair. The 17-year-old patient with diagnoses of interrupted aortic arch and ventricular septal defect presented after two previous operations (one left lateral thoracotomy and one median sternotomy) with a stenosed vascular graft between ascending and descending aorta. Surgery was done via re-sternotomy without cardio-pulmonary bypass. An extraanatomic graft was used to connect ascending and descending aorta. When performing the distal anastomosis, the heart was exposed using a standard suction device. This case demonstrates that the use of modern techniques may facilitate surgical approaches dramatically. In our opinion the above-described technique is the first choice for all patients requiring arch repair following multiple previous operations, performed via sternotomy and thoracotomy.     

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30°C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.     

Surgical treatment of a retrosternal pseudoaneurysm arising from the posterior aortic root

We report a case of a 60-year-old male with a retrosternal pseudoaneurysm arising from the posterior aortic root. He had undergone replacement of the aortic root and ascending aorta for an acute aortic dissection. His postoperative course was complicated with composite graft infection. During a redo surgery, femoro-femoral bypass was established prior to sternotomy via the right femoral artery and vein, and ten French cannulas were directly inserted into both carotid arteries through separate skin incisions for brain perfusion. When the sternum was divided, an occlusion balloon catheter introduced through the left femoral artery was inflated to maintain somatic perfusion without compromising clear vision of the operative field. Combined procedures with direct cannulation into both common carotid arteries and balloon occlusion of the distal aortic arch allowed us to safely perform replacement of the aortic root and ascending aorta in the patient with a retrosternal pseudoaneurysm.     

Simultaneous multi-vessel coronary artery bypass grafting, ischemic mitral regurgitation repair and descending aortic aneurysm replacement: analysis of technical points

The combination of coronary artery disease and its complications (ischemic mitral regurgitation etc.) with the aneurysm of the descending thoracic aorta is not a rare case. The single-stage correction of coronary/intracardiac/aortic lesions may be considered as a way of managing the combined patients. Simultaneous multi-vessel coronary artery bypass grafting, suture mitral annuloplasty and descending aortic aneurysm replacement with synthetic prosthesis is described. The operation was performed through the left thoracotomy with cardiopulmonary bypass established by the cannulation of the ascending aorta and of the right atrial appendage. Ventricular fibrillation and no clamping of the ascending aorta were used. The circulatory arrest was induced for the construction of the proximal anastomosis between the descending aorta and the synthetic prosthesis. No complications related to the operation were diagnosed for the 14-month follow-up. Several technical points seem optimal for the combined procedure: (1) Minimization of manipulations on the ascending aorta (using of pedicled left internal thoracic artery; construction of the proximal anastomoses with synthetic aortic prosthesis; unclamped ascending aorta). (2) Revascularization of all coronary areas and correction of intracardiac lesions through the left thoracotomy. Individual planning of the procedural technical points for every patient may provide a safe feasibility of the combined procedure.     

Acute intraoperative aortic dissection following axillary artery cannulation

We describe a 75-year-old woman who underwent right axillary artery cannulation in preparation for reconstruction of the aortic arch and the proximal descending aorta for athesosclerotic aortic aneurysm via a 'clamshell' incision. As soon as cardiopulmonary bypass was established, the ascending aorta and the aortic arch was dissected. The innominate artery was dissected including one-third of its circumferance anteriorly. Arterial perfusion was stopped immediately and the left femoral artery was cannulated to resume CPB. We proceeded with replacement of the ascending aorta, the aortic arch and the proximal descending thoracic aorta with a Dacron branched aortic graft. The patient recovered uneventfully. Arterial blood pressure was equal bilaterally.     

Protection of visceral organs with an aortic occlusion balloon catheter and by femoral perfusion in aortic arch replacement

A 68-year-old man developed hemoptysis. Prominent left 1st arch was pointed out by chest X-p, and enhanced computed tomography (CT) revealed 60-mm distal arch aneurysm. Protrusion of the aneurysm strongly suggested aorto-pulmonary fistula. The operation was performed via median sternotomy. Cardiopulmonary bypass was established with the ascending aorta cannulation. During systemic cool down, an aortic occlusion balloon (Equalizer) was inserted in the right femoral artery and its position was monitored by transesophageal echography. Femoral perfusion cannula was inserted in the right femoral artery distal to the site of the Equalizer insertion. When the rectal temperature reached 28 degrees C, Equalizer was inflated and femoral perfusion was started. After the aortic arch was incised, balloon-tipped cannula were inserted into the aortic arch vessels. At this point, separate antegrade cerebral perfusion and lower body perfusion were established. The aortic arch was replaced with woven Dacron tube graft. It took 60 minutes to accomplish distal anastomosis, and urination was 80 ml during this period. Postoperative course was uneventful without renal dysfunction. This method of visceral organ protection seemed to be useful for the patients with impaired renal or liver function and for the patients whose distal anastomosis is difficult.     

A case report of atypical coarctation of the aortic arch with thoracic aortic aneurysm

A 30-year-old woman was admitted to our hospital because of the abnormal shadow on chest X ray film and paralysis of right fingers. The preoperative aortogram and DSA showed atypical coarctation of the aortic arch with thoracic aortic aneurysm. We successfully performed extra-anatomical bypass with a 14 mm Cooley low porosity Ducron graft between ascending aorta and discending aorta. Her postoperative course was uneventful and discharged one month after the operation.     

Median sternotomy and extended left anterior thoracotomy for repair of traumatic aortic transection with ruptured right atrium

A 22-year-old man presented with traumatic aortic transtion associated with rupture of the right atrium and underwent urgent median sternotomy to repair the right atrium. A T-shaped extended left anterior thoracotomy was performed, and ruptured descending thoracic aorta was repaired under total bypass. A Y-shaped connector was inserted in the arterial catheter to allow cannulation of both ascending aorta and femoral arteries. A 4-cm long Hemoshield graft was used to repair the aortic transection. The patient made a full recovery and was discharged 13 days after the accident.     

Type A dissection caused by aortic cannulation during coronary artery bypass grafting; report of a case

A 71-year-old woman who had severe stenosis in the origin of the left anterior descending coronary artery with large diagonal branch was scheduled for coronary artery bypass grafting (CABG). After harvesting of bypass conduits, aortic cannulation was performed into the ascending aorta. Immediately after insertion of the cannula, however, the ascending aorta changed to a bluish color. Epiaortic ultrasonography revealed aortic dissection. Replacement of the ascending aorta was carried out using circulatory arrest under deep hypothermia. The intimal tear was located at the cannulation site. After this procedure, scheduled CABG the left internal thoracic artery to the left anterior descending coronary artery and the saphenous vein graft to the diagonal branch was performed. The proximal site of the saphenous vein graft was anastomosed to the replaced graft. The postoperative course was uneventful. Rapid identification and appropriate surgical management are necessary to minimize patient morbidity and mortality.