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.     

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.     

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.     

Open aortic stent grafting and prosthetic bypass in a child

Pseudoaneurysm is a major complication of percutaneous balloon angioplasty to treat recoarctation and restenosis after an interrupted aortic arch repair. Endovascular stent grafting to manage this complication has rarely been performed in children. We used a combination of open stent grafting and a prosthetic ascending aorta-to-descending aorta bypass to treat a pseudoaneurysm and ascending aorta stenosis in a 7-year-old child.     

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.     

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.     

Repair of aortic coarctation in patients more than 50 years of age.

BACKGROUND: Most patients with uncorrected coarctation of the aorta die before reaching age 50 years. In those who survive, the beneficial effect of surgical repair on systolic hypertension has been questioned. METHODS: Surgical repair of aortic coarctation was performed in 8 patients aged 51 to 73 years (mean, 58+/-9 years). Preoperative mean systolic pressure was 185+/-34 mm Hg and systolic gradient, 70+/-11 mm Hg. In addition, 3 patients had significant coronary artery disease. Severe calcification of the aortic arch and left subclavian artery was found in 3 patients. The surgical technique involved bypass of the coarctation with a Dacron tube graft (16 or 18 mm) in all patients. One patient underwent concomitant coronary artery bypass grafting. RESULTS: There were no operative or late deaths during a mean follow-up of 4.3 years. Mean systolic blood pressure decreased significantly in the postoperative period to 128+/-16 mm Hg (p < 0.001). At the last visit, systolic blood pressure was a mean of 127+/-9 mm Hg. Five patients were not taking antihypertensive medication. CONCLUSIONS: Surgical repair of aortic coarctation in patients more than 50 years of age with a Dacron tube bypass graft reduces systolic hypertension and the need of antihypertensive medication.     

Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation.

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 first results of an anatomically guided technique via the prior left thoracotomy approach without establishment of cardiopulmonary bypass. METHODS: Since 1989, five patients underwent anatomically positioned ascending-descending bypass grafting for treatment of recoarctation. Indication was a non-dilatable hypoplastic aortic arch segment; in two cases an additional isthmic restenosis was present. Inclusion criteria for our technique was an aorta ascending diameter large enough to allow partial clamping. Primary repair of aortic coarctation was end-to-end anastomosis in four patients and patch angioplasty in one. Mean age at primary repair was 5.5 years and at reoperation 16.1 years. Systolic pressure gradients at rest ranged from 35 to 70 mmHg; upper extremity hypertension was present in all patients. Operative technique consisted of performing a dacron or PTFE aorta ascending-descending bypass graft parallel to the aortic arch, size 18 or 20 mm in diameter, via the prior left thoracotomy. RESULTS: There were no intraoperative complications and all patients survived. Postoperative complications were left lung atelectasis with necessity of reintubation, pericardial effusion, and transient left diaphragm elevation, each in one patient. After 7-90 months all patients are free of symptoms, have normal blood pressure (with two patients being under anti-hypertensive medication), and have no echocardiographically measurable pressure gradients. CONCLUSIONS: Anatomically positioned aorta ascending-descending bypass grafting via the prior left posterolateral thoracotomy without cardiopulmonary bypass is a safe and efficient method for operation of complex recoarctation in patients with an acceptable size of the aorta ascendens.     

Extended aortic bypass

At the University of Alberta Hospital, six patients recently underwent placement of Dacron bypass grafts from the ascending aorta to the infrarenal abdominal aorta or femoral arteries for a variety of vascular problems. The operations were performed in patients with (1) multiple aortic coarctations, (2) congenital aortic arch interruption and congenital mitral stenosis, (3) recoarctation of the thoracic aorta after previous coaractation repair (two patients), (4) aortoiliac occlusive disease in a patient with multiple previous abdominal operations including an abdominal-perineal resection and left lower quadrant colostomy, and (5) idiopathic retroperitoneal fibrosis and multiple previous operations on the abdominal aorta. Surgical access was through midline sternotomy and laparotomy incisions, and groin incisions were used as required. Careful attention was paid to placing as much graft as possible in an extraperitoneal position. All patients survived the operation and had essentially uneventful postoperative courses with good results. This technique has previously been described. However, attention is drawn to it once again as an excellent means of bypassing the thoracic and abdominal aorta in selected patients with complex vascular problems.     

Cardiopulmonary bypass established via a sutured vascular graft in the presence of extraanatomic bypass

Cardiopulmonary bypass (CPB) was established via a sutured collagen sealed knitted Dacron graft in two patients who had undergone extraanatomic bypasses for lower limb ischemia, whose ascending aorta was not suitable for cannulation. One patient, with a history of femorofemoral bypass, underwent surgery for a ruptured aortic arch aneurysm (AAA) and the other patient, with a history of axillobifemoral bypass for chronic dissection involving the aortic arch and descending aorta, had unstable angina and underwent coronary artery bypass grafting. This technique of perfusion was found to be safe and effective for patients with an impaired ascending aorta who have undergone an extraanatomic bypass for the lower limb.     

正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形

目的总结正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形的外科治疗经验,以提高手术疗效。方法1997年7月至2008年7月,采用正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形31例,其中男20例,女11例;年龄31．9±11．7岁。合并的心脏畸形包括：主动脉瓣狭窄或关闭不全22例,二尖瓣狭窄或关闭不全9例,动脉导管未闭5例,升主动脉瘤4例,室间隔缺损3例,冠心病2例。解剖外旁路移植术包括升主动脉-腹主动脉旁路移植术22例,升主动脉-心包后降主动脉旁路移植术9例。同期手术包括主动脉瓣置换术16例,主动脉根部置换术6例,二尖瓣成形或置换术9例,升主动脉置换或成形术4例,动脉导管未闭缝合术5例,室间隔缺损修补术3例,冠状动脉旁路移植术2例。结果住院死亡1例（3．2％）,术后39d死于感染性中毒性休克。术后上、下肢收缩压压差较术前明显下降（13．7±10．2mmHg vs．64．2±25．3mmHg,P〈0．05）。随访27例,随访时间4～73个月,无晚期死亡、与人工血管相关的并发症和再次手术患者。结论正中切口解剖外旁路移植术是一期治疗成人及青少年主动脉缩窄合并心脏畸形的一种安全有效的手术方法。升主动脉腹主动脉旁路移植术及升主动脉-心包后降主动脉旁路移植术均可获得满意疗效。     

主动脉缩窄或主动脉弓中断合并心内畸形一期修复

目的 探讨采用经胸骨正中切口一期修复主动脉缩窄(CoA)或主动脉弓中断(IAA)合并心内畸形的治疗效果.方法 2002年7月至2009年6月,经胸骨正中切口行降主动脉远端和主动脉弓下缘端侧吻合术一期修复CoA或IAA合并心内畸形病儿43例,其中CoA 34例,IAA 9例(A型6例、B型3例),合并心内畸形包括室间隔缺损42例、动脉导管未闭34例、房间隔缺损12例、主动脉瓣下隔膜狭窄5例、二尖瓣关闭不全2例,右心室双出口1例.结果 手术死亡1例,为术后肺动脉高压和严重低心排血量综合征者.术后并发症包括严重低心排血量综合征3例,低氧血症6例,肺部炎症11例,肺不张14例,声音嘶哑19例,室上性心动过速23例.8例失访.34例随访3个月～5年,生活质量明显改善,心脏超声心动图和CT检查显示吻合口无明显再缩窄发生.结论 经胸骨正中切口,采用主动脉远端和主动脉弓下缘端侧吻合技术一期修复CoA或IAA合并心内畸形的手术早、中期效果良好,能明显减少术后再狭窄.     

Successful treatment for intraoperatively evolving acute aortic dissection in a neonate

Acute aortic dissection is a life-threatening condition. We report the case of a neonatal one-stage correction of coarctation and hypoplastic aortic arch repair plus ventricular septal defect closure. While dissecting the head vessels after cannulation of the ascending aorta and commencing cardiopulmonary bypass, type A aortic dissection evolved. This required immediate ascending aorta and aortic arch reconstruction with coarctation of the aorta resection under hypothermic circulatory arrest. The surgical management of this rather unique situation is discussed here.     

Total Simultaneous Repair of Coarctation and Intracardiac Pathology in Adult Patients

Background. Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures.

Methods. We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta–descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting.

Results. Double arterial cannulation, retrograde cardioplegia, large-bore aorto–aortic bypass grafts, and early use of -agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course.

Conclusions. Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta–descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.     

Surgical treatment for graft stenosis after repair of an interrupted aortic arch: Report of two cases

We report herein two cases of patients who underwent successful reoperation for graft stenosis after repair of an interrupted aortic arch (IAA). The first patient was a 10-year-old girl who suffered from upper limb hypertension 9 years after her initial operation. Cardiac catheterization revealed a pressure gradient of 55 mmHg across the repaired arch. At reoperation, a left subclavian turndown anastomosis was performed, following which the hypertension resolved and a car-diac catheterization done 5 years later demonstrated sufficient growth of the restored arch with no significant gradient. The second patient was a 17-year-old boy who suffered from general fatigue and intermittent hypertension 12 years after his initial operation. Cardiac catheterization revealed a gradient of 60 mmHg across the repaired arch. He underwent an extraanatomic ascending to descending aortic bypass employing an additional 18-mm graft, and a postoperative cardiac catheterization showed no gradient between the ascending and descending aorta. Our experience has shown that IAA should be repaired without prosthetic grafts if possible. Although extraanatomic bypass is useful for reducing the operative risks at reoperation, a large graft should be used to avoid the need for a third operation. For young children expected to outgrow a second graft, performing an endogenous anastomosis, such as a left subclavian turndown anastomosis, should be considered as an alternative. Received: June 14, 1999 / Accepted: March 24, 2000     

Combined surgical and endovascular approach to treat a complex aortic coarctation without extracorporeal circulation

Various therapeutic approaches have been proposed to treat complex coarctation of the aorta (eg, recoarctation, which requires repetitive interventions, or coarctation with a hypoplastic aortic arch). Resection followed by end-to-end anastomosis or by graft interposition is technically demanding and exposes the patient to considerable perioperative risks. Cardiopulmonary bypass and deep hypothermic circulatory arrest may be necessary to control the distal aortic arch. The role of stent technology in treating this type of lesion has not yet been defined. We present a 21-year-old woman with a recurrent coarctation of the aorta associated with a hypoplastic aortic arch and a pseudoaneurysm of the proximal descending aorta. She had undergone 4 previous interventions. Treatment consisted of a combined surgical and endovascular approach without cardiopulmonary bypass and included extraanatomic aortic bypass, partial debranching of the supraaortic vessels, and stent-graft insertion to exclude the aneurysm.     

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.     

Acute Type A Dissection Treated with Combined Endovascular Repair of Arch and Surgical Bypass of Arch Vessels from Descending Aorta

We report a case of an endovascular repair of a recurrent dissecting aneurysm of the aortic arch and dissection of carotid vessels, 3 years after surgical repair of aortic valve and ascending aorta for a type A dissection. We performed a bypass from the descending aorta to right, left common carotid artery (CCA), to left subclavian artery with no cardiopulmonary bypass and thereafter, total ascending and aortic arch stent grafting. We suggest considering total aortic arch stent grafting with bypass of arch vessels in cases of complicated acute type A dissection. In cases where the ascending aorta cannot be used as donor site for bypass, we suggest the use of the descending aorta.     

Ascending-distal abdominal aorta bypass for treatment of hypoplastic aortic arch and atypical coarctation in the adult

Repair of aortic coarctation is usually an easy operation. However, it can be very difficult under certain circumstances. These include operating on an adult or operating when specific anatomical variations, such as hypoplasia of the transverse aortic arch or calcification of the coarctation area, are present. We recommend that in such cases the situation be handled using ascending aorta-lower abdominal aorta bypass grafts rather than conventional resection and anastomosis of the coarctation itself. The cases of 2 patients are presented in whom a hypoplastic aortic arch associated with atypical coarctation was repaired using such a procedure.     

Extrathoracic repair of branch occlusions of the aortic arch.

Thirty extrathoracic operations in twenty-six patients with occlusive disease involving the primary branches of the aortic arch were reviewed. Spanning a fourteen year experience, these operations included carotid-subclavian artery bypass, retrograde common carotid artery thrombectomy, carotid-carotid artery bypass, and femoral-axillary artery bypass. Dacron bypass grafts were used primarily for reconstruction, but saphenous vein bypass and endarterectomy were also employed. Indications for operation, the presence of concomitant cardiovascular disease, surgical technics, patient survival, and late patency of the reconstructions were reviewed. One patient died postoperatively (3.85 per cent). All Dacron grafts were patent on late follow-up examinations. Low mortality and excellent late functional results make extrathoracic repair the approach of choice in the management of occlusive disease of the branches of the aortic arch.