Korean Circ J.  2016 Jul;46(4):556-561. 10.4070/kcj.2016.46.4.556.

Single Stage Repair for Aortic Coarctation associated with Intracardiac Defects Using Extra-Anatomic Bypass Graft in Adults

• Duvan I
• Ates MS
• Onuk BE
• Bakkaloglu B
• Sungur UP
• Kurtoglu M
• Karagoz YH

• KMID: 2344432
• DOI: http://doi.org/10.4070/kcj.2016.46.4.556

Abstract

BACKGROUND AND OBJECTIVES
Coarctation of the aorta in adulthood is generally associated with other cardiovascular disorders requiring surgical management. An extra anatomic bypass grafting from the ascending to descending aorta by posterior pericardial approach via median sternotomy could be a reasonable single stage surgical strategy for these patients.
SUBJECTS AND METHODS
Seven male patients aged between 14-41 years underwent an extra anatomic bypass grafting for coarctation repair concomitantly with the surgical management of the associated cardiovascular disorders via median sternotomy. Preoperative mean systolic arterial blood pressure was 161.8±24.5 mmHg, although the patients were under treatment of different combinations of antihypertensive agents. Additional surgical procedures were: aortic valve replacement (n=4), ventricular septal defect (VSD) closure (n=2), ascending aortic replacement (n=3) and Bentall procedure (n=1). None of our patients have been previously diagnosed or operated on for coarctation. Data were evaluated during their hospital stay and in post-operative follow-up.
RESULTS
The post-operative course was uneventful in all but one patient was re-operated on due to bleeding. There was neither mortality nor significant morbidity during the in-hospital period and all patients were discharged within 5-9 (mean: 6.3±1.5) days. The mean follow up period was 71.83±23 months (range: 23-95 months). Unfortunately one of our patients could not be contacted for a follow up period because of invalid personal data.
CONCLUSION
Coarctation of the aorta in adulthood associated with other cardiovascular disorders can be operated on simultaneously via an extra anatomic bypass grafting technique with low morbidity and mortality.

Keyword

Aortic coarctation; Associated disease; Median sternotomy; Bypass, graft

MeSH Terms

Adult*
Antihypertensive Agents
Aorta, Thoracic
Aortic Coarctation*
Aortic Valve
Arterial Pressure
Follow-Up Studies
Heart Septal Defects, Ventricular
Hemorrhage
Humans
Length of Stay
Male
Mortality
Sternotomy
Transplants*
Antihypertensive Agents

Figure

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  Fig. 1 Pre-operative view of postductal aortic coarctation (white arrow) concomitant with ascending aortic aneurysm (yellow arrow).

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  Fig. 2 Collateral arteries originating from the intercostal and internal thoracic arteries in postductal aortic coarctation.

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  Fig. 3 Proximal anastomosis of the extra anatomic bypass graft (yellow arrow) on the medial aspect of the replaced ascending aorta (white arrow).

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  Fig. 4 Extra anatomic bypass graft (yellow arrow) routing from descending (blue arrow) to ascending aorta (white arrow) through the left margin of the heart anterior to the main pulmonary artery.

Reference

1. Kenny D, Hijazi ZM. Coarctation of the aorta: from fetal life to adulthood. Cardiol J. 2011; 18:487–495.

2. Campbell M. Natural history of coarctation of the aorta. Br Heart J. 1970; 32:633–640.

3. Mulay AV, Ashraf S, Watterson KG. Two-stage repair of adult coarctation of the aorta with congenital valvular lesions. Ann Thorac Surg. 1997; 64:1309–1311.

4. Vijayanagar R, Natarajan P, Eckstein PF, Bognolo DA, Toole JC. Aortic valvular insufficiency and postductal aortic coarctation in the adult. Combined surgical management through median sternotomy: a new surgical approach. J Thorac Cardiovasc Surg. 1980; 79:266–268.

5. Powell WR, Adams PR, Cooley DA. Repair of coarctation of aorta with intracardiac repair. Tex Heart Inst J. 1983; 10:409–413.

6. Bigdeli AK, Schmitz C, Kaczmarek I, et al. Combined aortic valve replacement and extra-anatomic aorta ascending-descending bypass for recurrent aortic coarctation. Ann Thorac Surg. 2010; 89:e22–e24.

7. Sweeney MS, Walker WE, Duncan JM, Hallman GL, Livesay JJ, Cooley DA. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg. 1985; 40:46–49.

8. Edie RN, Janani J, Attai LA, Malm JR, Robinson G. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg. 1975; 20:558–566.

9. Kanter KR, Erez E, Willians WH, Tam VK. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg. 2000; 120:885–890.

10. Robicsek F. "Very long" aortic grafts. Eur J Cardiothorac Surg. 1992; 6:536–541.

11. Izhar U, Schaff HV, Mullany CJ, Daly RC, Orszulak TA. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg. 2000; 70:31–37.

12. Almeida de Oliveira S, Lisboa LA, Dallan LA, Abreu F CA, Rochitte CE, de Souza JM. Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results. Ann Thorac Surg. 2003; 76:1962–1966.

13. Wang R, Sun LZ, Hu XP, et al. Treatment of complex coarctation and coarctation with cardiac lesions using extra-anatomic aortic bypass. J Vasc Surg. 2010; 51:1203–1208.

14. Fedoruk L, Sett SS, Murphy JJ 3rd, LeBlanc JG, Patterson MW. Compression of mediastinal structures treated by extra-anatomic bypass grafting. J Card Surg. 2004; 19:343–345.

15. Sun LZ, Luo XJ, Liu YM. Single-stage treatment of aortic coarctation and aortic valve disease. Asian Cardiovasc Thorac Ann. 2003; 11:208–212.

16. Pethig K, Wahlers T, Tager S, Borst HG. Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass. Ann Thorac Surg. 1996; 61:1724–1726.

17. Patel Y, Jilani MI, Cho K. Coarctation of the aorta presenting in a 79-year-old male. Thorac Cardiovasc Surg. 1998; 46:158–160.

18. Park JH, Chun KJ, Song SG, et al. Severe aortic coarctation in a 75-year-old woman: total simultaneous repair of aortic coarctation and severe aortic stenosis. Korean Circ J. 2012; 42:62–64.