Coarctation of aorta with right aortic arch and anomalous left subclavian artery]

The occurrence of coarctation in patients with right aortic arch is extremely rare. We have encountered a 21-year-old man with anomalous left subclavian artery. He was diagnosed when he was 13. On angiography he exhibited a right aortic arch. The left common carotid artery, right common carotid artery and the right subclavian artery diverged from the proximal side of the coarctation. The left subclavian artery diverged from the distal side. The right brachial arterial pressures measured 158-72 mmHg, while the left brachial arterial pressures measured 98-80 mmHg. Clinical studies revealed no vascular ring and no other anomalies were found in this patient. An attempt at treatment was made with extra anatomical bypass grafting from the ascending aorta to the descending aorta. No pressure difference due to coarctation remained after operation.     

Anesthesiology problems in Takayasu's syndrome]

Takayasu's disease is a rare form of nonspecific obliterative panarteritis of unknown origin, mainly located at supraaortic, renal, and pulmonary arteries and resulting in multiple stenoses and occlusion of major arteries. Predominantly young women in the first three decades of life are affected. Absence of arm pulses, vascular bruits, and retinopathy are classic symptoms. Another symptom is hypertension of the lower extremities and hypotension of the upper extremities, thus potentially impairing cerebral perfusion. A 25-year-old female patient with a 2-year history of Takayasu's disease presented for therapeutic abortion on the grounds of her medical condition. There were significant stenoses of the left common carotid artery and the internal carotid artery. The left subclavian artery was totally obliterated. The arterial blood supply to the left arm was accomplished by the left vertebral artery via a subclavian steal syndrome. Brachial and radial pulses were absent in both arms. General, spinal or epidural anesthesia can produce arterial hypotension. Blood pressure assessment at the lower extremities does not allow conclusions about perfusion of supraaortic arteries and cerebral perfusion pressure. Thus, a paracervical block was performed; sedation and analgesia were achieved with small doses of midazolam and alfentanil. We planned that if general anesthesia became necessary we would induce anesthesia with etomidate and alfentanil and maintain anesthesia by mask ventilation with nitrous oxide in oxygen and supplementary doses of alfentanil. Invasive monitoring such as arterial or Swan Ganz catheterization, was contraindicated because of the possibility that inflamed vessels would become irritated. Therefore, we only monitored ECG, blood pressure at the leg, ventilation parameters, and oxygen saturation at the ear lobe by pulse oximetry.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery

A 10-year-old girl having bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery was found, on admission, to have no difference between upper and lower extremity blood pressure, but echocardiography revealed severe thoracic aorta coarctation and systolic blood pressure in the carotid arteries exceeding 200 mmHg estimated by Doppler ultrasonography. Magnetic resonance imaging and angiography demonstrated bilateral subclavian steal without esophageal compression. We reconstructed the aortic arch using the left subclavian artery and a reversed Blalock-Park procedure, then repaired the coarctation with a 14 mm woven double velor vascular graft. The girl was symptom-free following uncomplicated recovery from surgery. Doppler ultrasonography 2 weeks after surgery showed the pressure gradient across the aortic arch had decreased from 180 mmHg to 60 mmHg. This residual gradient at the anastomosis between the ascending aorta and left subclavian artery may improve as native vessels grow.     

Perioperative management of a patient with subarachnoid hemorrhage complicated with descending aortic dissection

A 62-year-old man with descending aortic dissection received general anesthesia for clipping of aneurysm of the cerebral artery. We chose a surgical operation for the aneurysm of the cerebral artery, and conservative therapy for the dissection of the aorta. We gave balanced anesthesia with blood pressure control using calcium channel blocker. Anesthesia was induced with propofol, fentanyl, and vecuronium, and maintained with isoflurane, fentanyl, nitrous oxide and oxygen. Transesophageal echocardiography was useful for checking dissection of the aorta. Perioperative course was uneventful.     

Acute popliteal arterial occlusion during extracorporeal circulation

A 79-year-old man underwent aortic arch replacement for thoracic aortic aneurysm. He had a history of smoking, coronary stenting for ischemic heart disease and replacement with artificial blood vessel for abdominal aortic aneurysm. Anesthesia was induced and maintained with midazolam, fentanyl, sevoflurane, and vecuronium. A 20 gage catheter was placed in the right radial artery and a 22 gage catheter in the left posterior tibial artery. Total circulatory arrest under profound hypothermia and retrograde cerebral perfusion were performed using extracorporeal circulation. After finishing anastomosis with artificial blood vessel, he was weaned from extracorporeal circulation. The pressure in the left posterior tibial artery was maintained at 15 mmHg, although the blood pressure in the right radial artery increased gradually. Then, the pressure in the left femoral artery in the operative field was the same as the pressure in the right radial artery. Therefore, we suspected the arterial line occlusion of the left posterior tibial artery. After the operation, we found the left leg and foot pale and cold with no pulsation on the left popliteal, dorsal pedis, and posterior tibial arteries. Further, acute left popliteal arterial occlusion was assessed by means of Doppler and left lower extremity angiography. We immediately performed the balloon-catheter embolectomy. However, as he developed compartment syndrome on the left lower limb due to reperfusion injury postoperatively, fascitomy was performed. On the 58th postoperative day, he was discharged from our hospital. Measurement by Doppler is useful for the early diagnosis of the lower leg arterial occlusion.     

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.     

A simple and safe operation method for brachiocephalic artery aneurysms

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.     

全身麻醉中连续无创动脉血压监测与有创动脉血压监测的比较

目的 评价麻醉期间TL-300系统测得的连续无创血压(continuous non-invasive arterial pressure,CNAP)和有创血压(invasive arterial pressure,IAP)监测的一致性和安全性.方法 择期全身麻醉手术患者72例,麻醉诱导前将动脉导管置入非优势手的桡动脉内行IAP监测,另一侧手臂连接TL-300系统行CNAP监测,记录IAP及相应时间点CNAP,以及相关的并发症.结果 CNAP与IAP所测SBP、DBP和MAP偏倚分别为(-0.6±7.0)、(-7.8±9.8)和(-5.8±6.2)mmHg(1 mmHg=0.133kPa),一致性界限分别为-14.6～13.4 mmHg、-27.4～11.8 mmHg、-18.2～6.6 mmHg,在其相应的一致性界限范围内所占比值分别为95.2％、96.1％和94.9％.两种BP监测方法的SBP、DBP和MAP的相关系数r分别为0.927、0.711和0.903 (P＜0.01).均未发生肢体缺血、坏死、感觉异常.结论 TL-300CNAP和IAP比较,有较高的相关性和一致性,提供无创实时连续、准确的BP监测,可安全用于全身麻醉手术患者.     

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.     

A case of coexisting descending thoracic aortic aneurysm and atypical aortic coarctation treated successfully by surgery using the thromboexclusion method

The thromboexclusion method was successfully applied to a 43-year-old male with aortitis syndrome. Preoperative aortogram showed a fusiform aneurysm of the descending aorta just below the left subclavian artery and atypical coarctation of the descending aorta distal to this aneurysm. Pressure gradient across the stenosis was about 70 mmHg. The technique of flow reversal and thromboexclusion was performed in this patient because of severe calcification in the aortic arch and the entire descending aorta. A long extra-anatomical bypass between the ascending aorta and the infrarenal abdominal aorta was made, and a permanent aortic clamp was placed across the aorta at the left subclavian artery. Hypertension in the arm disappeared immediately after the operation, and postoperative catheterization revealed no pressure gradient between the ascending and the abdominal aorta. Computed tomogram performed 18 days after the operation and aortogram done 44 days postoperatively disclosed thrombi formation in the aneurysm.     

A clinical study of cerebral perfusion during pulsatile and nonpulsatile cardiopulmonary bypass

The purpose of this study was to determine the effect of pulsatile flow on cerebral perfusion under cardiopulmonary bypass (CPB). Twenty-three patients who underwent cardiac operations were divided into two comparable groups: Group A (N = 11) had standard nonpulsatile flow, while in Group B (N = 12), a pulsatile pump was used. The blood flow of left common carotid artery and radial arterial pressure were continuously monitored during cardiac operation in both groups and cerebral vascular resistance was calculated. In Group B, the perfusion pressure of left common carotid artery was monitored and compared with that of radial artery. Arterial and internal jugular venous blood were sampled and the difference of cerebral A.V O2 contents and cerebral oxygen consumption was calculated. Cerebral vascular resistance in Group B (54.0 +/- 11.2% of the value of before-CPB) significantly decreased compared to that in Group A (72.2 +/- 11%) at the end of CPB (p less than 0.05). Pulse pressure following pulsatile CPB flow was 15.1 +/- 5.8 mmHg monitored in radial artery and it reduced to 8.5 +/- 5 mmHg in left common carotid artery. Although there was no significant difference in cerebral oxygen consumption of both groups during and just after CPB, the difference of cerebral A-V O2 contents of Group B was greater than Group A just after CPB. These data suggest that pulsatile flow may minimize the cerebral microcirculatory shunt during CPB, resulting from the reduction of cerebral vascular resistance.     

A clinical study on brain perfusion during cardiopulmonary bypass

The purpose of this study was to determine the optimum cerebral perfusion flow rate and pressure of the selective cerebral perfusion. Blood flows of the brachiocephalic and left common carotid artery in 34 patients were continuously monitored by means of electromagnetic flow meter during cardiac operations. Radial and common carotid arterial pressure were monitored simultaneously. Arterial and internal jugular venous blood were sampled and cerebral oxygen consumption was calculated. During steady state hypothermic cardiopulmonary bypass (CPB), mean cerebral perfusion flow was about 600 ml/min at CPB flow of 2.4 L/min/m2. Cerebral oxygen consumption was decreased to 50% of the prebypass level during steady state hypothermic CPB and then it returned to prebypass level after CPB. Common carotid arterial pressure was about 10 mmHg lower than radial arterial pressure during CPB. When CPB flow was remained at 2.4 L/min/m2, left common carotid arterial flow was not affected by common carotid arterial pressure within the range of 40 to 80 mmHg. Cerebral autoregulation might be preserved at this pressure level of the common carotid artery. When CPB flow was reduced from 2.4 L/min/m2, cerebral oxygen consumption was remained constant level until the flow reached to 1.6 L/min/m2, at which cerebral perfusion flow was about 400 ml/min. Data suggest that optimum cerebral perfusion flow during the selective cerebral perfusion may be about 600 ml/min although cerebral oxygen consumption was maintained when cerebral perfusion flow was reduced to 400 ml/min. Optimum cerebral perfusion pressure was 40-80 mmHg of carotid arterial pressure and when monitored in radial artery, more than 10 mmHg higher pressure should be required.     

Influence of the descending thoracic aortic cross clamping on bispectral index value and plasma propofol concentration in humans

BACKGROUND: In this study, the authors investigated changes in Bispectral Index (BIS) values and plasma propofol concentrations (Cp) after aortic cross clamping in the descending thoracic aortic aneurysm repair surgery during propofol anesthesia. METHODS: Prospectively, in 10 patients undergoing thoracic aortic surgery during total intravenous anesthesia with propofol, BIS values were recorded during cross clamping of the descending thoracic aorta. In this study, the rate of propofol infusion was controlled to keep the BIS value between 30 and 60 throughout surgery. Simultaneously, Cp values in the blood samples taken from the right radial artery (area proximal to cross clamping) and the left femoral artery (area distal to cross clamping) were measured. RESULTS: Approximately 15 min after initiating aortic cross clamping, BIS values in all cases started to decrease abruptly. Cp values of samples taken from the radial artery after cross clamping of the aorta were significantly (P < 0.05) increased compared with pre-cross clamp values (1.8 +/- 0.4 microg/ml), and the mean Cp after aortic cross clamping varied between 3.0 and 5.3 microg/ml. In addition, there were significant differences in the Cp values between radial arterial and femoral arterial blood samples throughout aortic cross clamping. Cp values in samples from the radial artery were approximately two to seven times higher than those from the femoral artery. CONCLUSIONS: This study showed that Cp values increased and BIS values decreased rapidly after aortic cross clamping in thoracic aortic aneurysm repair surgery during propofol anesthesia. These findings suggested that all anesthesiologists should control the infusion rate carefully, taking the abrupt changes in its pharmacokinetics into consideration, especially during cross clamping of the descending thoracic aorta.     

A case report of atypical coarctation of the aorta with coarctation and left subclavian arterial aplasia

A 18 year-old female was admitted to our hospital with hypertension of 190/100 mmHg in her right arm and 140/110 mmHg in the left arm. Femoral arterial pulsation was not palpable. Her physical status and growth of the lower limbs were normal. Aortography demonstrated slight coarctation with a pressure gradient of 10 mmHg and descending aortic stenosis with a pressure gradient of 80 mmHg. Main three branches from aortic arch were anatomically normal. However, the left subclavian artery distal to the origin of the left vertebral artery was not visualized and the axillary artery was perfused by collaterals. Atypical coarctation was replaced using a woven Dacron graft of 14 x 40 mm. Postoperatively proximal pressure decreased from 180/113 to 156/98 mmHg and there was no pressure gradient between proximal and distal of the graft. After six months blood pressure in the right arm gradually decreased to 120/78 mmHg.     

Repair of coarctation of the aorta in adults and hypertension

The aim of this study is to determine if surgical repair of coarctation in adults improves systemic hypertension. The charts of 23 consecutive patients (age range 13-36 years, mean 23.6+/-7) who underwent repair of aortic coarctation at the Atatürk University, Aziziye Hospital, between 1986 and 2000 were reviewed. There were 16 (70%) men and seven (30%) women. All patients had preoperative hypertension. Systolic blood pressure (BP) ranged between 150 and 200 mmHg, with a mean of 176+/-15 mmHg. Peak systolic gradient across the coarctation was 52+/-20 mmHg (range from 30 to 112 mmHg). There were no early or late deaths. Mean systolic BP values at the first postoperative evaluation were 176+/-15 mmHg (p<0.001 from preoperative values). Exercise testing revealed hypertensive response to exercise in three of 10 patients who had borderline hypertension at rest and without medication. Repair of coarctation of aorta even in adults is safe and improves systemic hypertension. To identify patients with potential hypertension, exercise testing should be performed. Impaired arterial dilatation may be an important contributor to exercise-related hypertension and late morbidity or mortality.     

Anesthesia for total and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis

We experienced anesthesia for total arch and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis. Because there was possibility that post coarctectomy syndrome would occur after repair of coarctation of aorta, administration of depressor that acts on renin-angiotensin-aldosterone and careful observation were needed postoperatively. In consideration of the development of collateral vessels, preoperative imaging evaluation was added and operative method in cardiopulmonary bypass was adjusted. Careful preoperative evaluation is very important in cardiac anesthesia.     

General anesthesia for a patient with pulmonary hypertension, bronchial asthma and obesity

The management of the patient with pulmonary hypertension is a challenge for the anesthesiologists because the risk of right-sided heart failure is markedly increased. We experienced a case of general anesthesia for a patient with pulmonary hypertension (mean pulmonary arterial pressure 39 mmHg), bronchial asthma and obesity. A 31-year-old woman was scheduled for arytenoid rotation for left recurrent nerve palsy. We applied routine monitors (noninvasive blood-pressure, five-lead electrocardiogram, pulse oximeter), and direct blood pressure monitoring through the radial artery. Anesthesia was induced with midazolam 4 mg, fentanyl 100 microg and sevoflurane 5%, and maintained with sevoflurane (1-2%) and nitrous oxide in oxygen. Surgery was completed in 100 minutes without any complications. We could successfully perform general anesthesia in a patient complicated by pulmonary hypertension, bronchial asthma and obesity, without invasive right-sided heart catheterization.     

A surgical case of atypical aortic coarctation using cardiopulmonary bypass.

We report a 44-year-old woman with atypical aortic coarctation accompanied by cerebral artery disease. She was hospitalized for vertigo. An extra-anatomic bypass between the ascending aorta and abdominal aorta was performed using partial cardiopulmonary bypass under moderate hypothermia to reduce the after load of the left ventricle and maintain cerebral blood flow and cerebral perfusion pressure. The postoperative course was uneventful and there was no postoperative neurological deficiency.     

Influence of the Descending Thoracic Aortic Cross Clamping on Bispectral Index Value and Plasma Propofol Concentration in Humans

Background: In this study, the authors investigated changes in Bispectral Index (BIS) values and plasma propofol concentrations (Cp) after aortic cross clamping in the descending thoracic aortic aneurysm repair surgery during propofol anesthesia.

Methods: Prospectively, in 10 patients undergoing thoracic aortic surgery during total intravenous anesthesia with propofol, BIS values were recorded during cross clamping of the descending thoracic aorta. In this study, the rate of propofol infusion was controlled to keep the BIS value between 30 and 60 throughout surgery. Simultaneously, Cp values in the blood samples taken from the right radial artery (area proximal to cross clamping) and the left femoral artery (area distal to cross clamping) were measured.

Results: Approximately 15 min after initiating aortic cross clamping, BIS values in all cases started to decrease abruptly. Cp values of samples taken from the radial artery after cross clamping of the aorta were significantly (P < 0.05) increased compared with pre-cross clamp values (1.8 +/- 0.4 [mu]g/ml), and the mean Cp after aortic cross clamping varied between 3.0 and 5.3 [mu]g/ml. In addition, there were significant differences in the Cp values between radial arterial and femoral arterial blood samples throughout aortic cross clamping. Cp values in samples from the radial artery were approximately two to seven times higher than those from the femoral artery.     

升主动脉-腹主动脉转流术治疗成人主动脉缩窄

目的 探讨升主动脉-腹主动脉人工血管转流术治疗成人主动脉缩窄的手术效果、随访结果并总结其临床经验.方法 2008年5月至2009年7月,应用升主动脉-腹主动脉人工血管转流术治疗成人主动脉缩窄9例,其中男4例,女5例;平均年龄42.6岁.所有病人均经桡动脉、足背动脉穿刺测压,根据术前、术后,桡动脉、足背动脉平均压差变化评价手术效果.结果 术后均治愈出院.术前桡动脉足背动脉平均压差36～63 mm Hg(1 mm Hg=0.133 kPa);术后24 h桡动脉足背动脉平均压差0～13 mm Hg,较术前明显缩小.随访1～13个月,术后上、下肢动脉平均压差均小于20 mm Hg,转流人工血管通畅,2例主动脉缩窄远端自体动脉部分闭塞.结论 升主动脉-腹主动脉人工血管转流术是治疗成人主动脉缩窄的有效手段.

Abstract：

Objective To explore the surgical effects and follow-up results in treating adult aortic coarctation patients using ascending aorta-abdominal aorta vascular prosthesis bypass and summarize the clinical experiences. Methods From May 2008 to July 2009, ascending aorta-abdominal aorta vascular prosthesis bypass surgery was performed in nine patients with adult aortic coarctation, among which, four were male, and five were female, with the average age of 42.6 years old. All patients had upper extremity hypertension, the systolic blood pressure difference between their upper extremities and lower extremities was 55 - 100 mm Hg, mean (70.2 ± 15. 6) mm Hg. Among which, seven cases showed descending aorta aneurysmal dilatation at coarctation segment distal end, with the wall thinning; two cases showed long segment stenosis; three cases showed aortic wall near coarctation segment was calcified. All cases belonged to complex aortic coarctation. All patients underwent radial artery and dorsalis pedis artery puncture manometry, the surgical effects were evaluated according to mean pressure difference changes between radial artery and dorsalis pedis artery before and after operations. Results All patients were cured and dispertension has been significantly improved, before operation, the mean pressure difference between radial artery and dorsalis pedis artery was 36 - 63 mm Hg, mean [(48.2 ± 5.6 ) mm Hg]; 24 hours after operation, the mean pressure difference between radial artery and dorsalis pedis artery was 0 - 13 mm Hg, mean [(6.2 ± 1.6) mm Hg], significantly reduced ( P ＜per extremity hypertension disappeared, no need for oral antihypertensive drugs, the mean pressure differences between upper extremities and lower extremities after operations were all less than 20 mm Hg, thoracoabodominal aorta main vessels multi-slice CT examination three months after operation showed that bypass vascular prosthesis was unobetructed, two cases showed that autologous artery at aortic coarctation distal end were partly occluded. Conclusion Ascending aorta-abdominal aorta vascular prosthesis bypass would be an effective means for the treatment of adult aortic coarctation patients.