Extraanatomic aortic bypass for repair of aortic coarctation

We describe two adult patients who underwent extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic coarctation through a median sternotomy and posterior pericardial approach. Of the two patients, one presented with coarctation and concurrent cardiovascular disorders, and the other, with residual coarctation. Cardiopulmonary bypass was established with double arterial cannulation in the aorta or axillary artery and the femoral artery ensure adequate perfusion proximal and distal to coarctation and bicaval cannulation. The heart was retracted cephalic and superiorly, and the descending thoracic aorta was exposed through the posterior pericardium. After achieving distal anastomosis, the graft was directed anterior to the inferior vena cava and lateral to the right atrium, and anastomosed to the right lateral aspect of the ascending aorta. A 14-mm graft was used. In one patient receiving concomitant procedures, mitral valve repair and replacement of the ascending aorta was performed after the distal anastomosis.     

Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy

BACKGROUND: Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS: Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS: No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS: Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.     

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The preoperative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.     

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.     

Right aortic arch with mirror-image branching and coarctation of the aorta--a case report]

The right aortic arch with coarctation of the aorta was reported. A 56-year-old woman admitted to the hospital because of headache and hypertension. Cardiac catheterization revealed the right aortic arch with coarctation of the aorta and 80 mmHg pressure gradient across the coarctation. The bypass operation with a 14 mm Dacron graft between the ascending to descending aorta was performed. There was no peak systolic pressure gradient between the ascending and descending aorta after bypass operation. This patient is the fourth case report with both mirror-image type right aortic arch and coarctation of the aorta.     

Surgical treatment of interrupted aortic arch with extraanatomical bypass simultaneous to coronary artery bypass grafting and aortic valve replacement

An interrupted aortic arch accompanied by further surgically reparable cardiac lesions is a rare combination in adult patients. We describe treatment of an interrupted aortic arch, coronary artery bypass grafting (CABG), and aortic valve replacement (AVR) performed simultaneously through median sternotomy in a 64-year-old man. The patient underwent surgery performed using standard cardiopulmonary bypass with cannulation of the ascending aorta and the right atrium, hypothermia (24.6degreesC), and blood cardioplegic arrest. Four aortocoronary vein grafts and pericardial aortic valve replacement were carried out. Finally, the posterior pericardium was opened, and a 16-mm prosthesis was anastomosed to the descending aorta during side clamping using a 4-0 monofilament continuous suture. Optimal placement of the prosthesis was obtained by guiding it to the ascending aorta laterally to the right atrium and passing it between the inferior vena cava and right inferior lung vein. The operation was carried out without complications, and the postoperative course was uneventful. Magnetic resonance imaging showed competent aortic valve prosthesis and highly decreased collateral flow via the internal mammary arteries. Postoperatively both inguinal pulses were present, and the patient was free of angina. In the presence of an interrupted aortic arch, extraanatomical bypass via the posterior pericardium between the ascending and descending aorta can safely be performed at the same time as CABG and AVR through a median sternotomy.     

Ascending-to-descending aortic bypass via right thoracotomy for complex (re-) coarctation and hypoplastic aortic arch.

OBJECTIVE: Operation for aortic recoarctation and/or residual hypoplastic arch represents a surgical challenge because of surrounding scar tissue in the coarctation area, hazard of spinal cord ischemia due to aortic cross-clamping, laceration of the recurrent nerve, and the choice of the best approach. We demonstrate the results of 52 operations of an extra anatomically bypass technique via right thoracotomy approach without establishment of cardiopulmonary bypass. METHODS: Since 1987, 52 patients underwent extra anatomically positioned ascending-descending bypass grafting. Indication was aortic recoarctation with concomitant hypoplastic aortic arch (45 patients), atypical coarctation of aortic arch (2 patients), congenital anomalies of aortic arch (2 patients) and concomitant aortic coarctation and associated cardiac problems that required surgical repair (2 patient), infected stent-graft of descending aorta (1 patient). Mean age was 19.3 years. Systolic pressure gradients at rest ranged from 35 to 90mmHg; upper extremity hypertension was present in all patients. Operative technique consisted of performing aorta ascending-descending bypass graft size 16 or 18mm in diameter, via right thoracotomy (in 51 patient) or sternotomy (in 1 patient). RESULTS: The mortality rate was 1.9% (1/52). Five patients returned to the operating room (in 3-5 days after operation) for a lymphorrhea complication. An arterial pressure gradient in the limbs was totally corrected. During a follow-up period of actually 79+/-54 months, no adverse event was noticed and antihypertensive medication was stopped in all patients. CONCLUSIONS: Ascending-to-descending aortic bypass via right thoracotomy is a safe and effective method for management complex (re-) coarctation and hypoplastic aortic arch.     

Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft

Eight patients with chronic Budd-Chiari syndrome resulting from coarctation of the inferior vena cava underwent operation. Transatrial dilatation was of no avail in the first case. The obstructed segment was directly visualized in the subsequent seven cases by a transthoracic, transdiaphragmatic, retroperitoneal approach. In these latter seven cases, severe hourglass constriction of the inferior vena cava was observed just above the right hepatic vein. There was no evidence of inflammation, extrinsic compression, or thrombosis. Retrohepatic cavoatrial bypass with an antibiotic-sterilized aortic homograft was unsuccessful in three patients. Five patients including one with homograft failure underwent successful retrohepatic cavoatrial bypass with a polytetrafluoroethylene graft (20 mm plain in four cases and 16 mm ringed graft in one case). These patients have been followed up for 21 months to 6 years with no recurrence of symptoms. The term coarctation of the inferior vena cava appears more appropriate than membranous obstruction of the inferior vena cava because of the operative findings in the present series.     

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children

OBJECTIVE: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem. METHODS: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs). RESULTS: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations. CONCLUSIONS: Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.     

Development of neo-coarctation in patients with transposed great arteries and hypoplastic aortic arch after Lecompte modification of anatomical correction

We report on three patients with kinking in the proximal aortic arch that developed after Lecompte modification of the arterial switch operation. Two patients had a previous subclavian patch repair of coarctation of the aorta and had an associated hypoplasia of the transverse aortic arch, and one patient had hemodynamically mild coarctation at the anatomical repair. A severe pressure gradient across the kinked area ("neo-coarctation") necessitating reoperation developed in one patient. The acute arch angulation appears to be due to an excessive posterior displacement of the ascending aorta by the anterior relocation of either the right or left main pulmonary artery branch from underneath the aortic arch. A foreshortened and frequently hypoplastic transverse aortic arch, a common association with coarctation of the aorta, appears to be especially vulnerable to the development of "neo-coarctation" after the Lecompte modification of the anatomical repair of transposed great arteries.     

Aortic coarctation in the adult: management of complications and coexisting arterial abnormalities with hypothermic cardiopulmonary bypass and circulatory arrest

OBJECTIVES: Adult patients with aortic coarctation may have complications after childhood repair. Other adult patients have coarctation and aneurysms of the aorta and the left subclavian artery. The optimal management of such cases is not clearly established. We evaluated the role of hypothermic cardiopulmonary bypass and circulatory arrest. METHODS: Thirteen adult patients (mean age 38 years) with coarctation and coexisting abnormalities of the aorta and left subclavian artery were treated. Five patients had pseudoaneurysms develop after bypass grafting (n = 3) or patch angioplasty (n = 2). These were detected a mean of 21 years (range 13-44 years) after the initial operation. Four pseudoaneurysms were asymptomatic, and 1 had ruptured. One patient had recurrent coarctation from fibrous obliteration of a 10-mm bypass graft inserted 15 years previously. The remaining 7 patients had aneurysms of the left subclavian artery (n = 5), aneurysms of the ascending aorta and arch (n = 1), or stenosis of the left subclavian artery (n = 1) in combination with moderate or severe coarctation. Resection and interposition graft replacement of the aneurysmal or stenotic aortic segments were performed in all cases with an interval of hypothermic circulatory arrest that averaged 44 +/- 5 minutes (range 33-54 minutes). Seven patients had interposition graft replacement of aneurysmal or stenotic left subclavian arteries. RESULTS: There were no in-hospital or late deaths (maximal follow-up 7 years). No patient had brain injury, paralysis, myocardial, respiratory, or renal failure. No patient has evidence of recurrent coarctation or aneurysm formation. CONCLUSIONS: Cardiopulmonary bypass with hypothermic circulatory arrest can safely be used in the treatment of complex adult coarctation. It permits accurate delineation of the anatomy with minimal dissection, avoidance of aortic clamping and sacrifice of intercostal arteries, precise interposition graft repair, and adequate protection of vital organs.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

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.     

升主动脉至胸降主动脉人工血管转流在主动脉缩窄外科治疗中的应用

目的：分析总结使用升主动脉至胸降主动脉人工血管转流术治疗成人型主动脉缩窄10例临床病例资料,探讨升主动脉至胸降主动脉人工血管转流术在临床中治疗主动脉缩窄的意义。方法中国医学科学院、北京协和医院心脏外科2006年1月-2015年12月共收治成人主动脉缩窄患者10例,其中男性患者7例,女性患者3例,年龄14~35岁,中位年龄27岁,其中1例合并主动脉瓣二瓣畸形及主动脉根部瘤样扩张,余均为单纯主动脉缩窄。10例患者静息情况下测量上下肢压差均大于20 mmHg (1 mmHg=0.133 kPa),术前评估无明确手术禁忌。10例均在体外循环下行升主动脉至胸降主动脉人工血管转流术,合并主动脉瓣二瓣畸形及主动脉根部扩张的患者,同时行Bentall术。结果无围术期死亡及大出血、脊髓缺血性损害等严重并发症,嘱托患者出院后3~6个月门诊复查,复测上下肢压差均小于20 mmHg,CTA结果提示未见动脉瘤、人工血管血栓形成等表现。结论利用人工血管从升主动脉转流至降主动脉是治疗胸主动脉缩窄的有效方法。     

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy

Abstract   Background and Aim: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. Methods: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistant hypertension, were noted. Results: Six male patients with a mean age of 20.8 ± 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm—one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 ± 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. Conclusions: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.     

Ascending Aorta-Abdominal Aorta Bypass: Indications,Technique, and Report of 12 Patients

Use of the supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation.     

Operation of mid-arch coarctation.

BACKGROUND: Coarctation occurring within the aortic arch is rare and may present difficulties during surgical repair. We describe the operative technique and outcome in 6 patients with this unusual anomaly. METHODS: Five patients had antegrade perfusion with circulatory arrest. Three patients with presubclavian narrowing (one presenting with type B dissection) were operated through extended left thoracotomy. Two precarotid and paracarotid lesions were approached through a median sternotomy. All patients were perfused antegradely from the ascending aorta and operated with hypothermic circulatory arrest. One patient who had a complex presubclavian coarctation after two previous repairs received an ascending aorta to abdominal aorta bypass graft without cardiopulmonary bypass. RESULTS: All patients survived operation and are well at a mean follow-up of 3.3 years after the procedure. None had cerebral problems or spinal cord injury. Renal function was unchanged. The mean (+/- standard error of the mean) resting gradient across the coarctation decreased from 42+/-4.0 mm Hg to 6+/-1.2 mm Hg (p = 0.0004). CONCLUSIONS: Hypothermic circulatory arrest using antegrade ascending aortic perfusion allows safe and effective repair of mid-arch coarctation. Complicated reoperations can be managed safely using ascending-to-abdominal aortic bypass.     

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.     

A case of left atrial thrombus complicated with coarctation of the aorta]

The case was a sixty one year old female who was diagnosed as having acute arterial embolism of right upper arm and underwent embectomy. The detailed examination which followed revealed left atrial myxoma and coarctation of the aorta. Due to the risk of embolism, an emergency operation was performed to install a right axillofemoral bypass with an 8 mm artificial graft. Left atrial myxoma was then excised in an operation using an artificial heart-lung apparatus. Pathological examinations of excised tumor offered no trace of tumor but only of left atrial thrombus. Postoperative results were satisfactory. The pressure difference between upper and lower arms was improved to 0.8 in pressure index from preoperative 0.5 and it became possible to control the blood pressure of upper arm within the level of 130 to 150 mmHg. Axillofemoral bypass is an effective method for a case like the above where a site of coarctation of the aorta cannot be directly repaired.     

Inferior T hemisternotomy after previous bypass grafting with the in situ RITA in front of the aorta

Aortic valvular surgery is often challenging in patients with coronary artery bypass (CABG) using in situ right internal thoracic artery (RITA) crossing in front of the aorta to the left anterior descending artery (LAD). Full sternotomy and aortic dissection result sometimes in graft injury and subsequent myocardial ischemia. The benefit of an inferior T hemisternotomy through the second intercostal space is discussed. The grafts are neither dissected nor clamped, and the access to the aortic root is excellent. Graft lesions are avoided. The absence of graft clamping does not seem to impair the myocardial function.