HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sabine Daebritz Bruno J. Messmer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Daebritz, S. Articles by Messmer, B. J. Search for Related Content PubMed PubMed Citation Articles by Daebritz, S. Articles by Messmer, B. J.

Eur J Cardiothorac Surg 1999;16:519-523
© 1999 Elsevier Science NL

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

^a Department of Thoracic and Cardiovascular Surgery, ‘Klinik für Thorax-, Herz- und Gefäßchirurgie’, Universitätsklinikum der RWTH, Pauwelsstraße 30, 52057 Aachen, Germany
^b Department of Pediatric Cardiology, ‘Kinderkardiologische Klinik’, Universitätsklinikum der RWTH, Pauwelsstraße 30, 52057 Aachen, Germany
^c Department of Internal Medicine I, ‘Medizinische Klinik I’, Universitätsklinikum der RWTH, Pauwelsstraße 30, 52057 Aachen, Germany

Corresponding author. Department of Thoracic and Cardiovascular Surgery, University Hospital, Pauwelsstrasse 30, D-52057 Aachen, Germany. Tel.: +49-241-808-9221; fax: +49-241-888-8454
e-mail: sdaebritz{at}aol.com

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 
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.

Key Words: Aortic recoarctation • Hypoplastic aortic arch • Posterolateral thoracotomy • Bypass grafting • Surgical treatment

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 
First successful resection and end-to-end anastomosis of coarctation of the aorta was performed by Crafoord and Nylin in October 1944 [1] followed by Gross and Hufnagel in 1945 [2]. Meanwhile, the subclavian flap technique [3] has become an additional standard surgical procedure particularly in neonates.

Because of the increasing number of complex and non-complex recurrent coarctations after surgical treatment with a varying frequency of 1.5–43% [4–12], the problems of reoperation have become a focus of attention. These are the distorted anatomy in the area of coarctation due to surrounding scar tissue with the hazard of damaging intercostal arteries, the recurrent laryngeal and phrenic nerve, and the risk of spinal cord ischemia if the aorta is cross-clamped without some type of bypass procedure.

In 1973, Weldon [13] propagated bypass grafts as a solution for these problems – avoiding dissection of the scar tissue and cross-clamping of the aorta by using partial exclusion clamps. In contrast to a left thoracotomy [13], Edie (1975) [14] used a combined approach via left postero-lateral thoracotomy and sternotomy. Since then different bypass techniques for recurrent coarctation repair have been described [4,7,15–20]. Aorta ascending-descending bypass grafts were placed extraanatomically without exception (Table 1).

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 
Between 1989 and 1997, three male and two female patients, mean age 16.1 years (range: 11.9–25.0 years) and mean body weight of 59.7 kg (range: 42–68 kg), underwent anatomically positioned aorta ascending-descending bypass grafting for treatment of recurrent aortic coarctation with or without an additional hypoplastic distal arch. Selection criteria for this technique were an ascending aorta of adequate size for partial exclusion with a side-biting clamp and the absence of significant intracardiac defects. Hospital records and follow-up examinations were reviewed in order to analyse pre-, intra- and postoperative courses. Special attention was given to the pressure gradient between ascending and descending aorta based on pressure measurement on the arms and legs, echocardiography and cardiac catheterization data, to the presence of arterial hypertension, and to the evidence of left ventricular hypertrophy.

At the time of the primary repair, the mean age of the patients was 5.5 years (range: 1.5–11.4 years). An end-to-end anastomosis was performed in four cases and patch angioplasty in one. The average time interval between primary operation and reoperation was 10.6 years (range: 5.9–13.6 years). One patient had had primary repair abroad, the others were operated on in our institution. None of the patients had undergone simultaneous repair of other cardiac defects. In four patients preperative angiograms were available. To assess aortic arch hypoplasia, the aortic diameter between left carotid and left subclavian artery was compared to the diameter of the distal descending thoracic aorta. The ratios were 0.6, 0.8, 0.92, and 1.0, respectively.

Indication for reoperation was given 3.9–12.7 years (mean: 11.6 years) after the initial operation and was based on pressure gradient measurement between arms and legs and echocardiography investigations in all patients. Cardiac catheterization revealed hypoplasia of the aortic arch between left carotid and left subclavian artery in four cases with an additional restenosis of the isthmus region in two cases. In the fifth patient the hypoplastic aortic arch segment extended from the brachio-cephalic trunk to left subclavian artery. Cardiac catheterization confirmed echocardiographically determined systolic pressure gradients at rest across the aortic arch and coarctation of 35–70 mm Hg. An upper extremity hypertension with an average systolic blood pressure in the right arm of 163 mm Hg (range: 147–194 mm Hg) and a mean diastolic pressure of 78 mm Hg (range: 67–100 mm Hg) was found in all patients. A right arm-left arm pressure gradient of more than 20 mm Hg at rest was present in all patients varying from 23 to 49 mm Hg (mean: 35 mm Hg). Three patients received permanent antihypertensive medication (atenolol one patient, atenolol and hydrochlorothiazide one patient, prazosin one patient). ECG revealed left ventricular hypertrophy in two patients with a Sokolow–Lyon-Index of 4.9 and 3.8 mV, respectively. Indication for surgical intervention was an anatomical situation not suitable for primary balloon dilatation.

	3. Operative technique

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 
All five patients were operated on using the same operative technique with external cooling to a core temperature of 33.6–31.0° for safety reasons. A left posterolateral thoracotomy through the fourth intercostal space with excision of the skin scar was performed. The adhesions between the chest wall and lung were dissected to free the descending thoracic aorta. The pericardium was incised ventral to the phrenic nerve with great care taken to avoid damaging it. The ascending aorta was dissected from the pulmonary artery and looped with a teflon band. Systemic anticoagulation (1 mg heparin/kg) was performed. A partial exclusion clamp was placed on the ascending aorta under continuous blood pressure control of the right radial and femoral artery. A tailored Dacron-or PTFE graft of 18 mm in diameter was used in two cases and of 20 mm in three. The graft was anastomosed end-to-side using a running 4-0 Ticron or PTFE suture. The aortic arch and the tissue in the recoarctation area were left untouched. The graft was placed anatomically parallel to the native aortic arch (Fig. 1). A partial exclusion clamp was placed on the descending aorta maintaining a mean femoral artery pressure of at least 60 mmHg. This anastomosis was performed end-to-side again with a running 4-0 Ticron or PTFE suture. After the clamp was released, heparin was antagonised with protamin. One chest tube and an intrapericardial drainage were inserted and the chest was closed.

View larger version (26K): [in this window] [in a new window]   Fig. 1. Drawing of an anatomically placed aorta ascending-descending bypass graft.

	4. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

After a mean follow-up time of 29 months (range: 7–90 months) all patients remained free of symptoms. Echocardiography did not reveal any measurable gradients between aorta ascendens and descendens. There was no considerable blood pressure difference between the arms or the right arm and the legs. Systolic and diastolic blood pressure was normal in all patients, but two patients were under antihypertensive medication. Sokolow–Lyon-Index remained elevated in those two patients who had signs of left ventricular hypertrophy in ECG before reoperation.

	5. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 
The incidence of aortic recoartation after surgical correction varies between 1.5 and 43% [4–12] depending on age [6,10,12] or weight [5] at initial repair. A correlation between incidence and surgical technique is discussed controversially: Rubay [11] did not find any difference. In contrast, Messmer [9] reported on a high restenosis rate for patch angioplasty and subclavian displacement technique whereas the subclavian flap technique yielded to excellent results after surgical repair in early infancy. The investigations of Zehr [12] confirmed a high incidence of recoarctation for patch angioplasty and a low incidence for subclavian flap technique. Furthermore, recoarctation is associated with a hypolastic aortic arch in 26–42% [18,21].

Indication for reintervention is a systolic arm-leg pressure gradient of more than 20–30 mmHg at rest or a reduction in diameter of more than 50% in angiography combined with hypertension [17,18,22]. Balloon dilatation yields to good results in selected cases with circumscript restenosis [23].

Mortality rate for repair of aortic recoartation varies from 0 to 7% and is often due to massive intraoperative bleeding [4,7,16–18]. Postoperative morbidity is mostly due to phrenic or recurrent nerve damage, chylothorax, residual gradients and persistent hypertension [4,18]. Spinal cord ischemia is an uncommon, but hazardous complication due to cross-clamping of the aorta [10].

The surgical technique for reoperation depends on the type of initial repair, on the length of aortic narrowing particularly on the site of the aortic arch, and on the presence of concomitant cardiac disease as well as on the age of the patient. Therefore, no single surgical technique applies to all patients.

In patient with circumscript restenosis, ballon dilatation or resection and end-to-end anastomosis is an often performed procedure [4,13,17,18]. If the lengths of the aortic narrowing exceeds a certain distance, tube graft interposition [17], patch angioplasty [4,7,17], or subclavian flap technique are necessary [7,18]. Patch angioplasty, however, is related to the development of mycotic or false aneurysms in short and long-term follow-up [24]. Besides, enlargement of the aortic arch with a patch, which may be necessary in up to 26% of the patients [18,25], requires complete dissection of the arch and the establishment of CBP.

The hazard of spinal cord ischemia due to aortic cross-clamping and laceration of the recurrent nerve in the surrounding scar tissue led to the development of tube bypass grafting procedures. In 1973 Weldon [13] described tube bypass grafting procedure, placing the graft form the transverse aortic arch or left subclavian artery to the descending aorta. The latter technique derives from the original Clagett operation [26]. Since then, tube bypass grafting has been performed in various ways with the proximal anastomosis on the subclavian artery or the ascending aorta and the distal anastomosis on the descending thoracic or abdominal aorta, or even femoral artery. In these procedures the grafts are placed extra-anatomically [4,7,14–16,19,20].

We demonstrated our experience with anatomically positioned aorta ascending – descending bypass grafts via the former left lateral thoracotomy and without establishment of CBP for recoarctation in selected patients. The present results confirm the low complication rate which has been described for tube grafting techniques in general [7,13,14,15,19] and which is in contrast to other surgical procedures [4,17,18]. Therefore, bypass techniques are particularly recommended for patients who undergo second reoperation [15,18,20].

We did not use sternotomy [15,19,20], extended thoracotomy combined with sternotomy [14,16], or right thoracotomy [7] as approach. To our point of view there are no advantages in these approaches for the repair of isolated recoartation. No operative problems with severe adhesions of the lung occurred using the former left thoracotomy. Besides, there are no additional scars; this may be of importance with regard to morbidity and cosmetic concerns especially in female patients. In contrast, we agree that in patients with additional intracardiac lesions sternotomy and establishment of CBP as reported by Barron [19] and Jacob [16] is necessary.

We did not use any kind of CBP in our technique for repair of isolated recurrent coarctation. This has been discussed controversially in literature [7,15,16,19,20]. Lange [17] recommends the use of CPB and hypothermic cardiocirculatory arrest with a mortality rate of 5.9% for recurrent coarctation, tolerating the complications related to extracorporal circulation. We monitored femoral artery pressure continuously to prevent accidental cross clamping of the descending aorta performing the distal anastomosis. Additional core cooling can be used if probatory clamping shows low pressure in the femoral artery, but would not have been necessary in our patients. Therefore, the size of the descending aorta is not a limiting factor for this technique.

We did not perform this technique with graft diameters less than 18 mm. This is in contrast to many authors who have used graft diameters of 10, 12 and 14 mm [7,15,16,19]. We consider a graft diameter of 18 mm or more safe to prevent from the development of a gradient due to patients growth. Thus, the limiting factor for our technique is the diameter of the ascending aorta which has to be large enough to allow partial clamping. Therefore, this technique does not apply for younger patients with a small ascending aorta.

At follow-up all patients were free of symptoms and did not show any measurable gradients in echocardiography. The most common complication of patch angioplasty – the development of aneurysms – has not been observed by us nor by other authors after tube grafting techniques [7,14]. All patients had normal arterial blood pressure postoperatively, but two were under anti-hypertensive medication. Long-term follow-up will give further information on the development of blood pressure in these patients. It is well known that the age at primary repair is the major risk factor for persistent hypertension [6,8,10].

In conclusion, anatomically positioned aorta ascending-descending bypass grafting is a safe and effective surgical treatment for recoarctation in selected patients, particularly if aortic arch hypoplasia is present. We recommend the same approach as for the first operation (posterolateral thoracotomy). Cardiopulmonary bypass is not considered necessary. Graft diameter should not be less than 18 mm to allow growth of the patient without development of a gradient. Thus, the size of the ascending aorta is the limiting factor for our technique. The development of blood pressure should be independent of the surgical technique if there are no residual gradients.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Operative technique 4. Results 5. Discussion References

 

1. Crafoord C., Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Cardiovasc Surg 1945;14:347-361.
2. Gross R.E. Surgical correction for coarctation of the aorta. Surgery 1945;18:673.
3. Waldhausen J.A., Nahrwold D.L. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532.[Medline]
4. Beekmann H.R., Rocchini A.P., Behrendt D.M., Rosenthal A. Reoperation for coarctation of the aorta. Am J Cardiol 1981;48:1108-1114.[Medline]
5. Brouwer M.H.J., Kuntze E.E., Ebels T., Talsma M.D., Eijgelaar A. Repair of aortic coarctation in infants. J Thorac Cardiovasc Surg 1991;101:1093-1098.[Abstract]
6. Brouwer M.H.J., Erasmus M.E., Ebels Tjark, Eijgelaar A. Influence of age on survival, late hypertension, and recoarctation in elective aortic coarctation repair, including long-term results after elective aortic coarctation repair with a follow-up from 25 to 44 years. J Thorac Cardiovasc Surg 1994;108:525-531.[Abstract/Free Full Text]
7. Caspi J., Ilbawi M.N., Milo S., Bar-El, Yaron, Roberson D.A., Thilenius O.G., Arcilla R. Alternative techniques for surgical management of recoarctation. Eur J Thorac Cardiovasc Surg 1997;12:116-119.
8. Cohen M., Fuster V., Steele P.M., Driscoll D., Mc Goon D.C. Coarctation of the aorta, longterm follow-up and prediction of outcome after surgical correction. Circulation 1989;80:840-845.[Abstract/Free Full Text]
9. Messmer B.J., Minale C., Mühler E., van Bernuth G. Surgical correction of coarctation in early infancy: does surgical technique influence the result?. Ann Thorac Surg 1991;52:594-603.[Abstract]
10. Pennington D.G., Liberthson R.R., Jacobs M., Scully H., Goldblatt A., Daggett W.M. Critical review of experience with surgical repair of coarctation of the aorta. J Thorac Cardiovasc Surg 1979;77:217-229.[Medline]
11. Rubay E., Sluysmans T., Alexandrescu V., Khelif K., Moulin, Vliers A., Jaumin P., Chalant C.H. Surgical repair of coarctation of the aorta in infants under one year of age. J Cardiovasc Surg 1992;33:216-221.[Medline]
12. Zehr K.J., Gillinov A.M., Redmond J.M., Greene P.S., Kan J.S., Gardner T.J., Reitz B.A., Cameron D.E. Repair of coarctation of the aorta in neonates and infants: a thirty-year experience. Ann Thorac Surg 1995;59:33-41.[Abstract/Free Full Text]
13. Weldon C.S., Hartmann A.F., Jr, Steinhoff N.G.., Morrissey J.D. A simple, safe, and rapid technique for the management of recurrent coarctation of the aorta. Ann Thorac Surg 1973;15:510-519.[Medline]
14. Edie R.N., Janani J., Attai L.A., Malm J.R., Robinson G. Bypass grafts for recurrent or complex coarctation of the aorta. Ann Thorac Surg 1975;20(5):558-566.[Abstract]
15. Grinda J.-M., Mace L., Dervanian P., Folliguet T.A., Neveux J.-Y. Bypass grafts for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg 1995;60:1299-1302.[Abstract/Free Full Text]
16. Jacob T., Cobanoglu A., Starr A. Late results of ascending aorta – descending aorta bypass grafts for recurrent coarctation of aorta. J Thorac Cardiovasc Surg 1988;95:782-787.[Abstract]
17. Lange R., Thielmann M., Schmidt K.G., Bauernschmitt R., Jakob H., Hasper B., Ulmer H., Hagl S. Spinal cord protection using hypothermic cardiocirculatory arrest in extended repair of recoarctation and persistent hypoplastic aortic arch. Eur J Thorac Cardiovasc Surg 1997;11:697-702.
18. Ralph-Edwards A.C., Williams W.G., Coles J.C., Rebeyka I.M., Trusler G.A., Freedom R.M. Reoperation for recurrent aortic coarctation. Ann Thorac Surg 1995;60:1303-1307.[Abstract/Free Full Text]
19. Barron D.J., Lamb R.K., Ogilvie B.C., Monro J.L. Technique for extraanatomic bypass in complex aortic coarctation. Ann Thorac Surg 1996;61:241-244.[Abstract/Free Full Text]
20. Sweeny M.S., Walker W.E., Duncan J.M., Hallmann G.L., Livesay J.J., Cooley D.A. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1984;40(1):46-49.[Abstract]
21. Campell J., Delorenzi R., Brown J., et al. Improved results in newborns undergoing coarctation repair. Ann Thorac Surg 1980;30:273.[Abstract]
22. Weber H.S., Cyran S.E., Grzeszczak M., Myers J.L., Gleason M.M., Baylen B.G. Discrepancies in aortic growth explain aortic arch gradients during exercise. J Am Coll Cardiol 1993;21:1002-1007.[Abstract]
23. Hijazi Z.M., Fahley J.T., Kleinman C.S., Hellenbrand W.E. Balloon angioplasty for recurrent coarctation of aorta, immediate and long-term results. Circulation 1991;84:1150-1156.[Abstract/Free Full Text]
24. Kirsch M.M., Peery B., Spooner E. Management of pseudoaneurysm following patch grafting for coarctation of the aorta. J Thorac Cardiovasc Surg 1977;74:636.[Medline]
25. Morrow W.R., Huhta J.C., Murphy D.J., McNamara D.G. Quantitative morphology of the aortic arch in neonatal coarctation. JCC 1986;8(3):616-620.
26. Clagett O.T., Jampolis R.W. Coarctation of the aorta. Arch Surg 1951;63:337-348.

This article has been cited by other articles:

				T. Goto, Y. Tsutsumi, T. Kawai, and H. Ohhashi Total arch replacement of late aneurysm after bypass grafting for coarctation of the aorta Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 176 - 177. [Abstract] [Full Text] [PDF]

				V. Arakelyan, A. Spiridonov, and L. Bockeria Ascending-to-descending aortic bypass via right thoracotomy for complex (re-) coarctation and hypoplastic aortic arch Eur. J. Cardiothorac. Surg., May 1, 2005; 27(5): 815 - 820. [Abstract] [Full Text] [PDF]

				N. Kang, A. J. B. Clarke, I. A. Nicholson, and R. B. Chard Circulatory arrest for repair of postcoarctation site aneurysm Ann. Thorac. Surg., June 1, 2004; 77(6): 2029 - 2033. [Abstract] [Full Text] [PDF]

				P. A. Berdat, V. Gober, and T. Carrel Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults Interactive CardioVascular and Thoracic Surgery, June 1, 2003; 2(2): 133 - 137. [Abstract] [Full Text] [PDF]

				S. Fraund, A. Boning, J. Scheewe, and J. T. Cremer Antero-axillary access for hypoplastic aortic arch repair Ann. Thorac. Surg., January 1, 2002; 73(1): 278 - 280. [Abstract] [Full Text] [PDF]

				C. Manganas, J. Iliopoulos, R. B. Chard, and G. R. Nunn Reoperation and coarctation of the aorta: the need for lifelong surveillance Ann. Thorac. Surg., October 1, 2001; 72(4): 1222 - 1224. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sabine Daebritz Bruno J. Messmer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Daebritz, S. Articles by Messmer, B. J. Search for Related Content PubMed PubMed Citation Articles by Daebritz, S. Articles by Messmer, B. J.