Anomalous origin of the right pulmonary artery from the ascending aorta: a report of three cases

Three patients with anomalous origin of the right pulmonary artery from the ascending aorta were reported. Case 1 was a 16-day-old girl with the right pulmonary artery arising from the base of the ascending aorta. Division and direct anastomosis of the anomalous vessel to the pulmonary trunk were successfully performed. Case 2 was a 4-month-old girl with the kinked and stenotic right pulmonary artery arising from the distal ascending aorta. At the time of surgery, however, the right pulmonary artery had been completely occluded and the pulmonary hypertension of the main pulmonary trunk had been disappeared. The chest was closed without any corrections. Case 3 was a 17-month-old girl with the stenotic right pulmonary artery arising from the distal ascending aorta. The stenotic lesion of the right pulmonary artery was longitudinally incised and anastomosed with the PTFE graft in an end-to-end fashion, followed by the end-to-side anastomosis of the graft and the pulmonary trunk.     

Modification of the Cabrol as a bailout procedure in complicated bicuspid valve aortopathy

The Cabrol technique is reserved where the conventional 'button' or Bentall techniques fail to maintain a tension-free anastomosis between the coronary arteries and aortic conduit. However, the side-to-side anastomosis of the interposition graft that connects the coronary ostia with the aorta in the Cabrol, may lead to kinking or tension, and subsequent occlusion. We present a case of successful Cabrol modification in a patient with bicuspid aortopathy where the graft to the right coronary artery was anastomosed directly onto the valved conduit and the graft to the left main stem onto the previous right aortocoronary graft in a T-fashion.     

Surgical management of univentricular heart with subaortic obstruction

In children with a univentricular heart and a rudimentary subaortic chamber, surgical relief of subaortic obstruction caused by a restrictive bulboventricular foramen is associated with high morbidity and mortality. A 6-year-old child with a univentricular heart of the left ventricular type, a rudimentary subaortic chamber, and atresia of the left-sided atrioventricular valve had pulmonary artery banding in infancy. Severe subaortic obstruction subsequently developed. At operation, the pulmonary artery was transected and the stump was anastomosed directly to the posterior aspect of the ascending aorta, diverting left ventricular blood into the aorta through the pulmonary valve. The distal pulmonary artery was anastomosed side-to-side to the ascending aorta to provide pulmonary blood flow. Cardiac catheterization fifteen months after the operation demonstrated an excellent hemodynamic result. When the pulmonary artery is adequate in size, a bypass operation by way of an anastomosis between the ascending aorta and the pulmonary artery is a relatively safe and effective means of relieving the ventricular outflow obstruction caused by a restrictive bulboventricular foramen.     

Arterial switch operation for transposition of the great arteries with situs inversus and mirror image dextrocardia

We report a successful arterial switch operation for complete transposition of great arteries with atrial and visceral situs inversus totalis and mirror image dextrocardia in a 12-day-old infant girl. The aorta was located left side-by-side to the pulmonary trunk with a single coronary artery (mirror image of 1RLCx). After French maneuver, the posterior circumference of the neo-aorta was reconstructed. Then the coronary button was transplanted into the neo-aorta with a trap door technique carefully avoiding any twist and over-stretch. The neo-pulmonary trunk was reconstructed with an autologous pericardial patch and sutured to the longitudinal incision made into the left central pulmonary artery. The baby was discharged from hospital and has been doing well without any morbidity relating myocardial ischemia.     

A complication of coronary angiography: fractured and retained intraaortic catheter

The complications linked directly to coronary artery catheter itself are very rare. We presented a case in which the broken right coronary artery catheter was successfully removed from the ascending aorta. The removal of catheter was accomplished via an aortic incision, which was created for saphenous vein graft in the site of anastomosis during an emergency coronary artery bypass graft surgery. We believe that a broken catheter in the aorta is a catastrophic event, which could be removed safely in the operating room even with concomitant bypass surgery.     

Posterior reduction aortoplasty for left pulmonary artery compression after Norwood procedure

All patients following the Norwood I procedure have a very large ascending aorta. This can lead to extrinsic compression of the surrounding vessels. We report a case of left pulmonary artery compression secondary to an aneurysmal neo-aorta and describe a technique of posterior reduction aortoplasty to decompress the left pulmonary artery.     

Simplified method for total correction of interrupted aortic arch with ventricular septal defect in infancy.

Type A interrupted aortic arch with a ventricular septal defect (VSD) in a 3-month-old infant was successfully corrected with the aid of profound hypothermia, limited cardiopulmonary bypass, and total circulatory arrest. The aortic arch was reconstructed by side-to-side anastomosis of the ascending aorta and the main pulmonary artery and then creation of a tube from the anastomotic orifice to the patent ductus arteriosus (PDA) by using a superabundant flap of the anterior wall of the main pulmonary artery. The pulmonary arteriotomy and VSD then were closed. The operative field can be approached easily through a median sternotomy with minimum dissection. Cardiac catheterization and angiocardiography 2 months later demonstrated a satisfactory reconstruction of both the aortic arch and the pulmonary artery.     

Palliative repair of aortic atresia associated with tricuspid atresia and transposition of the great arteries.

Successful palliative repair of aortic atresia and hypoplastic aortic arch associated with tricuspid atresia in a neonate is described. The repair consisted of reconstruction of the hypoplastic aortic arch with an equine pericardial patch, division of the patient ductus arteriosus, connection of the pulmonary artery to the aorta, implantation of the proximal part of the ascending aorta into the main pulmonary artery, and anastomosis of a polytetrafluoroethylene graft 5 mm in diameter between the right ventricular outflow tract and the central pulmonary artery, which was transferred anteriorly to the main pulmonary artery.     

Inhaled Nitric Oxide to Newborns and Infants after Congenital Heart Surgery on Cardiopulmonary Bypass: A Dose-response Study

Systemic artery to pulmonary artery saphenous vein shunts have been created in patients with tetralogy of Fallot. Anatomical alterations in the vein and haemo-dynamic function of the shunts have been studied with cineangiography in 14 patients. A gradual widening of the vein graft develops, but this can be prevented by using a tubular Dacron stockinette on the outside of the vein. The widening of the vein graft does not cause unwanted increase in the pulmonary flow, as evaluated from cine-angiographic study of the pulmonary circulation. The flow through the shunt is distributed to both pulmonary arteries. Five of the 14 patients had a previous Blalock anastomosis, in which the flow was less than in the vein graft when the same amount of contrast medium was injected at the same distance from the vein shunt and Blalock anastomosis. The flow was distributed only to the pulmonary artery that had the Blalock anastomosis. Stenosis in the subclavian artery in the Blalock procedure was frequently found.     

Anomalous origin of the right pulmonary artery from the ascending aorta.

Five cases of anomalous origin of the right pulmonary artery from the ascending aorta were seen at our hospital. Patients 1 and 2 had an intact right pulmonary artery originating from a right posterior aspect (proximal form), and primary anastomosis of the right pulmonary artery and main pulmonary trunk was performed. Patients 3 and 4 showed a narrowing right pulmonary artery originating from near the base of the innominate artery (distal form). The stenotic right pulmonary artery was reconstructed with an 8-mm graft in patient 3, whereas patient 4 became inoperable because complete obstruction had developed in the right pulmonary artery during the 3 months that the patient was waiting to undergo operation. In patient 5, primary anastomosis was undertaken, but morphologically the anomalous origin was of the distal form, so the occurrence of stenosis in the reconstructed right pulmonary artery was a matter of concern. The morphological type was found to be related to the surgical options in this anomaly. Therefore, primary anastomosis was considered the best choice for a correction of the proximal form, whereas a graft interposition with a resection of the stenotic portion on the right pulmonary artery was deemed preferable in the distal form.     

Unifocalization of Major Aorto-Pulmonary Collateral Arteries in Pulmonary Atresia and Ventricular Septal Defect Using Antibiotic Sterilized Pulmonary Homograft: A Case Report

A unifocalization procedure in a 9-year-old girl with pulmonary atresia, ventricular septal defect, and major aortopulmonary collateral arteries (MAPCAs) was performed using an antibiotic sterilized pulmonary homograft. A tailored pulmonary homograft was used as an interposition graft to anastomose the pulmonary artery to the larger MAPCA after a side-to-side anastomosis had been done between the two MAPCAs. The pulmonary homograft was connected to the right subclavian artery with a 6-mm Gore-Tex shunt. Postoperative oxygen saturation (SaO₂) levels were satisfactory and a postoperative angiogram showed good unifocalization of the pulmonary vasculature. (J Card Surg 1994;9:115–119)     

Vascular Complications After Simultaneous Pancreas and Kidney Transplantation: A Case Report

A 51-year-old patient with type I diabetes and end-stage renal disease was qualified for a simultaneous kidney and pancreas transplant. The procedure was performed in a typical manner: arterial anastomosis to the right common iliac artery, the graft's portal vein with inferior vena cava, and side-to-side duodenal intestinal anastomosis. The kidney was implanted retroperitoneally.Six months after the transplant, the patient reported pain in the right lower abdomen, and imaging examinations revealed arterial anastomosis. Reconstruction of the right common iliac artery was performed with a Gore-Tex prosthesis and the pancreatic artery reanastomosed to the right external iliac artery. After the surgery, the function of the transplanted pancreas deteriorated, the level of C-peptide was decreased, and the patient required low doses of insulin. After another 8 months, the imaging studies revealed an aneurysm located in the bifurcation of the aorta up to the anastomosis of the pancreatic graft artery with the iliac artery. The patient was qualified for the implantation of an endovascular of 2 prosthesis, which improved the graft's function. After another 2 months, the presence of an aneurysm at the endovascular prosthesis was found again. The patient was requalified for endovascular prosthesis implantation. Currently, there is no aneurysm but the function of the pancreas graft is impaired, though the kidney graft function is good.Patients after simultaneous kidney and pancreas transplant are a group of patients with an increased risk of vascular complications. Treatment should take place in a multidisciplinary center.     

Left coronary artery from the pulmonary artery: Physiological considerations of surgical correction

A 13-year-old boy with anomalous origin of the left coronary artery from the pulmonary artery has been studied before and after anastomosis of the artery to the aorta, using a saphenous vein graft. There was suggestive evidence of improved left ventricular function following operation. The presence of associated mitral regurgitation is suspected from the auscultatory findings.     

Coronary artery bypass grafting using side-to-side anastomosis

Recently, to obtain better long-term patency after coronary artery bypass grafting (CABG) arterial conduits such as internal mammary arteries (IMAs) and the right gastroepiploic artery have been frequently used. For coronary site anastomosis, end-to-side anastomosis is common. These conduits have a smaller diameter than the saphenous vein graft, so that, usually, longitudinal slits are made on the distal end of these grafts to obtain a more effective anastomotic orifice area. However, there is a potential for anastomotic leakage due to mismatch between the incision of the coronary artery and the arterial graft. We report here the efficacy of side-to-side anastomosis using small arterial conduits. This method has several advantages. Firstly, there is no chance of anastomotic leakage, since the coronary incision and graft incision can be perfectly matched. Secondly, if there is at least a 5-mm distance between the distal end of the graft incision and the surgical clip, the graft incision can be extended during anastomosis for adjustment. Thirdly, the distal end of the graft can be held beyond the surgical clip by forceps without damaging the arterial graft, which makes it easier for the anastomosis to be performed. Finally, the anastomosis can be checked by passing a probe through the distal end of the graft after removing the surgical clip. Also dye can be injected from the distal end of the graft at "Off Pump CABG", intraoperatively. This technique can be applied not only for distal end anastomosis, but also for proximal end, using free IMA to the ascending aorta and to make a Y-graft.     

Additional aortopulmonary anastomosis for subaortic obstruction in the Rastelli-type repair for the Taussig-Bing malformation

In the Taussig-Bing malformation, residual subaortic obstruction from a hypertrophied subaortic conus is often a problem at the time of intraventricular repair. To alleviate this problem, during a Rastelli-type repair involving an extracardiac valved conduit and an intraventricular connection from the ventricular septal defect to both aortic and pulmonary outflows, an additional side-to-side anastomosis between the ascending aorta and the proximal portion of the divided pulmonary artery can be performed, creating a supplementary outflow for the left ventricle. This method was used in 2 patients who had anteroposterior transposition of the great arteries, with 1 long-term survivor.     

The inherent limitations of sequential arterial bypass grafts: A hemodynamic study

While proximal bypass graft flows are known to increase by the sequential technique, the possibility of a "steal phenomenon" caused by the intermediate anastomosis has been raised. We compared graft and distal flow rates using simple reversed vein versus sequential bypass grafts in a canine model. A blind segment was created by occluding the common iliac artery above and the superficial femoral artery below a profunda femoris artery equivalent, which served as runoff from the blind segment. Reversed saphenous vein harvested from the contralateral thigh in seven anesthetized dogs was used to perform a simple common iliac artery to superficial femoral artery bypass. Graft and distal superficial femoral artery flow were measured with a calibrated flow probe of appropriate diameter (3-5 mm). A sequential side-to-side vein graft to arterial blind segment anastomosis was then added and flow measurements repeated after equilibration. Mean graft flow increased by 20 cc/min with the sequential technique (p = 0.05), while distal flow actually decreased by 1 cc/min (NS). Although no "steal phenomenon" was demonstrated, distal flow was not significantly improved by the sequential technique. We conclude that no convincing case based on presumed hemodynamic superiority can be made for performing sequential bypass in preference to standard reversed vein bypass. The increased potential for technical error introduced by the additional anastomosis and the lack of any demonstrable augmentation in distal flow suggest inherent limitations of the technique, and caution against its widespread use.     

Vein holder for coronary bypass surgery

Two types of vein holder were designed to facilitate coronary bypass surgery. One is designed for vein graft-to-coronary artery anastomosis and is particularly useful for the side-to-side anastomosis in sequential grafting. The other is designed for vein graft-to-aorta anastomosis and enables anastomosis by one surgeon. The vein holder holds the vein graft in a three-dimensional position without the need of forceps, which protects the vein graft wall from crush injuries caused by vascular forceps.     

A new vein holder for side-to-side saphenous-coronary anastomosis]

A new vein holder for a side-to-side anastomosis between a vein graft and the coronary artery is described. The holder is consisted of two nerve hooks, and those distance is adjusted. The technique for creating the diamond anastomosis is also described.     

Foldback technique for aortic anastomosis of free right internal thoracic artery in coronary artery bypass grafting

We herein report a new technique that we term “foldback plasty” for stenosis-free proximal anastomosis of free arterial grafts without using any other interposition materials. The arterial graft is first anastomosed to the aorta in side-to-side fashion, leaving 1 cm of remnant tissue at the proximal end. The reverse side of the graft is then opened longitudinally, starting at the proximal end, to just distal to the aortic anastomosis site. The new proximal graft flap is folded back and sutured onto the graft to close the longitudinal opening. The proximal anastomosis site is enlarged only by the graft tissue, and stenosis can be avoided even if the graft has a small caliber.     

Onlay patch for complete intercostal artery preservation during thoracic and thoracoabdominal aortic aneurysm repair

BACKGROUND: Replacement of the thoracic aorta is associated with a potential for interruption of the blood supply to the spinal cord leading to paralysis. Techniques have been proposed to ameliorate this risk, including reimplantation of the intercostal arteries. We present a technique to simplify this approach. METHODS: In patients with extensive aneurysmal disease, a standard approach to the thoracic aorta via a left thoracotomy is performed. The patient is placed on full cardiopulmonary bypass with moderate hypothermia. The proximal anastomosis is performed unclamped with circulatory arrest. After completing the proximal and distal anastomosis separately, an onlay patch of Dacron is created and placed along the entire back wall of the aorta to cover all of the intercostal arteries. A side-to-side anastomosis between the patch and the distal graft is then performed and subsequently the anastomosis tested by retrograde flow. RESULTS: The technique allows direct inspection of all suture lines, tested to an adequate pressure, so that postoperative bleeding is minimal. CONCLUSION: Techniques to lessen the risk of paraplegia associated with aortic surgery include reimplantation of the intercostal arteries. This technique allows each suture line to be tested and easily visually inspected prior to closure of the chest.