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Eur J Cardiothorac Surg 2005;27:815-820
© 2005 Elsevier Science NL

Ascending-to-descending aortic bypass via right thoracotomy for complex (re-) coarctation and hypoplastic aortic arch

Valery Arakelyan*, Alexey Spiridonov, Leo Bockeria1

Department of Vascular Surgery, Bakoulev Scientific Center of Cardiovascular Surgery, 135 Roublevskoe shosse, 121552 Moscow, Russian Federation

Received 20 September 2004; received in revised form 18 January 2005; accepted 20 January 2005.

* Corresponding author. Address: 8, korp.7 Leninsky Prospekt, 117931 Moscow, Russian Federation. Tel.: +7 95 237 28 71/+7 95 127 91 48; fax: +7 95 237 21 72. (E-mail: leoan{at}online.ru).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Surgical technique
 4. Results
 5. Discussion
 6. Conclusions
 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 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.

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


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Surgical technique
 4. Results
 5. Discussion
 6. Conclusions
 References
 
In spite of the fact that the outcomes of the surgical management of aortic coarctation are quite satisfactory, a certain group of patients need reoperation because of stenosis at the site of correction. Additionally, there is definite evidence of an annually growing population of such patients [1,2]. This circumstance is linked with:

• an increase in the number of infants operated on according to the life-threatening conditions, in the presence of a small aortic diameter,
• an extensive introduction into clinical practice of the noninvasive and mini-invasive research modalities (transesophageal and transthoracic echocardiography, computed tomography, MRI, digital subtraction angiography),
• inadequacy of surgical intervention due to technical errors,
• uncorrected hypoplasia of the aortic arch, the frequency of which, according to the reported data, reaches 65%.

Reoperations on the descending thoracic aorta remain one of the most challenging problems in the field of modern vascular surgery [3]. Interventions for such menacing pathology may be attempted only by the surgeons experienced enough in reconstructive operations on the thoracic aorta. It is to be noted that the rate of calcification of the aortic arch and isthmus, diffuse tubular hypoplasia of the aortic arch and adjacency of aortic arch branches are evident limitations of the quick-developing modern interventional technologies such as percutaneous balloon angioplasty and endografting [1,4].

In view of the high risk of intraoperative hemorrhagic complications and focusing on protection of the vital organs from ischemia, reoperations in the majority of cases are accomplished under cardio-pulmonary bypass [1,3,5,6,7] that increases, to a known extent, the risk of intro- and postoperative hemorrhagic events. Invasiveness of an access, injury to the pulmonary tissue and aorta, the probability of massive blood loss, and hemodynamic disorders related to the clamping of the arch and descending thoracic aorta determine the high surgical risk. Apart from the technical difficulties, the factors that may impact on the choice of the technique of repeat intervention are as follows: the type of the first operation, the degree and length of stenosis, severity of the scarry-commissural process, collateral circulation, and coexistent pathology. All these force the surgeons to continue the search for novel techniques for correction of stenosed anastomoses on the thoracic aorta, which will be safer for the patient's life and technically more feasible.

The present study aims at attracting the surgeons attention to aortoaortic bypass grafting from the ascending to the descending thoracic aorta as a technology which will allow an adequate correction of hemodynamics in patients presenting with coarctation and recoarctation syndrome. Also, the objective is to popularize the given treatment method which is safer and less invasive as compared to the present-day types of direct and bypass interventions employed in repeat reconstructive surgery of the thoracic aorta.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Surgical technique
 4. Results
 5. Discussion
 6. Conclusions
 References
 
Between 1987 and 2004, 52 patients seen at the Department of Arterial Pathology, Bakulev Scientific Center of Cardiovascular Surgery, Russian Academy of Medical Sciences were provided aortoaortic bypass grafting by an explant, from the ascending to the descending thoracic aorta via right-sided thoracotomy. Forty-five patients (of these 18 persons had hypoplasia of the distal segment of the aortic arch) were operated on for aortic recoarctation; 1 patient underwent operation for associated aortic coarctation and ischemic heart disease and 1 more patient for aortic coarctation coupled with aortic and mitral valvular disease; 2 patients were operated on for congenital abnormalities of the aortic arch and coarctation syndrome and another 2 patients for segmental aplasia (atresia) of the aortic arch between the left common and left subclavian arteries. In 1 patient, aortoaortic bypass grafting was accomplished as the first stage of operation for suppuration of the stent-graft of the entire descending thoracic aorta. At the second stage, the patient underwent, via left-sided thoracotomy, the evacuation of the infected graft with ligation of the thoracic aorta at the level of the left subclavian artery and above the diaphragm.

By the time of operation the mean age of the patients constituted 19.34±9.13 years (from 10 to 45 years). The average time interval between primary operation and reoperation was 10.07±10.95 years (range: 1–30 years). Explants manufactured by different companies and of varying modifications (fluorolon-lavsan, ‘Basex’, ‘Proto-graft’, ‘USCI’, ‘Vascutec’, and ‘Gore-Tex’) measuring 14–20mm in diameter (mean 16mm) were used as bypasses.

Three patients were provided simultaneous operations. The operation in question was supplemented by nephrectomy for contracted right kidney (1 patient), by coronary artery bypass grafting of the diagonal and anterior inter-ventricular branches of the left coronary artery for chronic ischemic heart disease (1 patient), and grafting of the aortic and mitral valves (1 patient).

The cumulative data and the type of the initial operation are presented in the Table 1.


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  		Table 1. Causes of recoarctation and the indications for (re)operation
 
In as much as the technique of the above-indicated operation has not been described in the available literature, we thought it desirable to highlight it in Section 3 in more detail.


   3. Surgical technique
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Surgical technique
4. Results
 5. Discussion
 6. Conclusions
 References
 
Operations were performed without resorting to cardiopulmonary bypass (except for 2 simultaneous operations—coronary artery bypass grafting and replacement of the mitral and aortic valves) under normothermia. A wide lateral thoracotomy was accomplished along the 4th or 5th intercostal space on the right with the patient lying on the left side. A segment of the descending thoracic aorta was exposed over a length of 6–10cm. Of note, we tried to ligate only the right intercostal arteries, namely not more than 1 pair. Distal anastomosis was established by 5/0 prolene blanket sutures on parietally retracted aorta, without preliminary heparinization. A fragment of the explant measuring 20–25cm in length was used. The anastomosis was constructed wide, oblique. After completion of anastomosis and its inspection for leakage, the graft was clamped at once above the anastomosis followed by complete re-establishment of blood flow in the descending aorta (Fig. 1).



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  		Fig. 1. End-to-side graft-to-aorta distal anastomosis is performed.

 
The next stage consisted in dissection of the pericardium while the ascending aorta was exposed to the length ample for its parietal retraction and adequate anastomosis formation. The free end of the explant was laid on the flattened arch to the front from the root of the right lung to avoid its compression. Proximal anastomosis was established after excision of the explant excess. The ascending aorta was retracted in this case along the anteroright wall (Fig. 2), anastomosis was established with 4/0 prolene blanket sutures. After anastomosis was inspected for leakage (the clamp from the graft in the area of distal anastomosis was removed), the blood flow was re-established. Operations were completed by draining the pericardium and right pleural cavities (Fig. 3).



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  		Fig. 2. The ascending aorta is opened.

 


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  		Fig. 3. Pericardial cavity drainage.

 
The surgical technique was slightly different in patients who had undergone simultaneous operations. In case of associated aortic coarctation and ischemic heart disease (the first aortoaortic bypass grafting performed at the Department) the operation was carried out via sternotomy access. Under conditions of cardiopulmonary bypass and drug- and ice-chip-induced cardioplegia distal anastomoses were established side-to-side and end-to-end, respectively, between autovenous bypass and the involved diagonal branch and the anterior interventricular branch of the left coronary artery (‘jumping’ bypass). Then a segment of the 18mm explant was sewn on the descending thoracic aorta. To expose the descending thoracic aorta, we rotated the stopped heart, dissected the pericardium and displaced the esophagus medially. After decannulation, we established proximal anastomoses between the graft and autovenous bypass and the ascending aorta. In the other case, we diagnosed, together with recoarctation syndrome, the lack of right renal function whereupon the operation was performed via two thoracotomy accesses along the 5th intercostal space on the right, during which we established proximal anastomosis between the 18mm explant and the ascending aorta, and via thoracophrenolumbotomy along the 10th intercostal space on the right. During the latter procedure, we evacuated the right kidney and constructed distal anastomosis with the descending thoracic aorta.

In the patient with concomitant valvular disease, simultaneous operation was also performed via right-sided thoracotomy along the fifth intercostal space. From the beginning, we established distal anastomosis between the 18mm explant and the descending thoracic aorta above the diaphragm. Afterwards under cardiopulmonary bypass, we replaced the aortic and mitral valves and only after re-establishment of cardiac activity, discontinuance of CPB and decannulation, we formed proximal anastomosis end-to-side between the aortoaortic explant and the descending aorta.

In the patient with suppuration of the endograft, operation was performed via two accesses. The first stage involved aortoaortic bypass grafting from the ascending to the descending thoracic aorta via right-sided thoracotomy along the 5th intercostal space (distal anastomosis was constructed at the level of the medial peduncle of the diaphragm). After the patient was turned to the right side we removed the infected graft via left-sided thoracotomy, followed by ligation of the descending thoracic aorta at the level of the left subclavian artery and above the diaphragm.


   4. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Surgical technique
 4. Results
5. Discussion
 6. Conclusions
 References
 
The short- and long-term results of 52 aortoaortic bypass graftings from the ascending to the descending aorta are beneficial. The patients were extubated on the operating table or over the immediate hours after surgery. Blood loss did not exceed 700ml. In the postoperative period, AP gradient between the upper and lower limbs was reestablished with systemic AP being normal (systolic AP dropped from 173.5±25.8 to 138±16.4mmHg whereas the pathological arterial pressure gradient between the arms arid legs decreased from 57.5±11.4 to 6.4±5.2mmHg). Five patients returned to the operation room (in 3–5 days after operation) for a lymphorrhea complication. The complication incidence is determined by anatomical peculiarities of the position of thoracic lymphatic duct and distal third of the descending thoracic aorta. We regard the surgical method—suture of damaged branches of thoracic duct—as the principal method of lymphorrhea arrest, which allowed arresting lymphorrhea in all patients. We have not observed such complications for the last 5 years. One patient died on the 28th day after operation from acute cardiopulmonary insufficiency as a result of the collapsed right-sided chylothorax—the lymphatic clot occupied all the pleural cavity thereby leading to the collapse of the lung and compression of the right heart (the patient's parents flatly declined rethoracotomy to remove lymphorrhea).

The long-term results were followed up in 38 patients over the period as long as 15 years (79±54 month) (Fig. 4). The patients were examined 6 and 12 months after operation. Then they were regularly (every year) provided control medical prophylactic examination. It included mainly X-ray and ultrasound procedures (ultrasound Doppler, echocardiography), examination by the cardiologist, and by the additional diagnostic techniques—exercise tests, duplex scanning of the brachiocephalic arteries, angiography, and computed topography. When analyzing the long-term results, we evaluated both the patient's general condition and the degree of aortic patency. In the long-term postoperative period, arterial pressure returned to normal and the pressure gradient did not exceed 10mmHg in 82% of patients. Residual hypertension was present in 4% of patients. However, it was well amenable by hypotensive therapy. The beneficial results of operation in the long-term follow up period allowed us to make a conclusion about reversibility of myocardial hypertrophy in patients with normal arterial pressure. The electrocardiogram demonstrated minimization of hypertrophy and overload of the left heart. Echocardiography indicated that hypertrophy diminished due to the lowering of the thickness of the posterior wall of the left ventricle. In this patient group, the heart size and its pump function returned to normal, the cardiac output rose, and physical tolerance increased more than 2-fold. No lethal outcomes were recorded in the long-term period.



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  		Fig. 4. Angiografia and CT in 15 years after operation.

 

   5. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Surgical technique
 4. Results
 5. Discussion
6. Conclusions
 References
 
The frequency of operations for unsatisfactory long-term outcomes of the surgical management of aortic coarctation reaches 60% [8,9]. The problem of aortic recoarctations is fairly pressing because, first of all, of the necessity of performing operations according to the life-threatening indications in the early childhood [10,11]. As shown by the reported data, the incidence of aortic arch hypoplasia in infants undergoing operations for aortic coarctation accounts for 70%. There is no doubt that this circumstance increases the risk of recoarctation at the later periods of life [10,11]. We would like to emphasize that nowadays the attitude toward isthmoplasty has become more watchful because of the high incidence of recoarctations, false aneurysms and steal syndrome, linked with the use of the left subclavian artery gained.

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.

Anatomic repair may be complicated by the need for extensive mobilization of the aorta, control of collateral blood vessels, the possibility of parenchymal lung injury, damage to the recurrent laryngeal or phrenic nerves, chylothorax, and spinal cord ischemia [12]. The most feared complication of aortic surgery is paraplegia and risk of spinal cord injury. The risk of these complications increase with prolonged aortic cross-clamp time and older age [12].

The staff-members of the Department have gained significant experience with direct operations for coarctation and recoarctation using the grafting technique and end-to-end technology. However, in view of the regulations we cannot dwell upon the indications for or specific features of these operations in the present work. Nevertheless, it is to be noted that despite the fact that aortoaortic bypass grafting has strongly consolidated its position at the Department in the series of operations in question, the share of direct operations exceeds 60–70%.

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 [14]. 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 [7,15].

Several reports [16,17] describe the outcome of ascending aorta-to-descending aorta bypass grafting through combined left thoracotomy and median sternotomy.

In 1980, Vijayanagar et al. [18] described an adult patient with coarctation of the aorta and severe aortic valve regurgitation. Ascending aorta-to-descending aorta bypass was performed by exposing the descending thoracic aorta through the posterior pericardium and placing the graft around the left margin of the heart. Since these initial descriptions, additional investigators have used the posterior pericardial approach to the descending aorta [7].

Most of these procedures require cardiopulmonary bypass, in cases of concomitant hypoplastic aortic arch, deep hypothermic circulatory arrest is needed for augmentation of the stenotic segment, exposing the patient to increased risk of cerebral dysfunction, cerebrovascular accident, and increased bleeding.

We demonstrated our experience with ascending–descending aorta bypass grafts via former right thoracotomy and without establishment of cardiopulmonary bypass for recoarctation in selected patients. The present results confirm the low complication rate. Its advantage is an opportunity to perform an operation from one approach, without cardiopulmonary bypass, beyond the area of the previous surgical intervention.

Nonsurgical interventional procedures are possible for native or recurrent coarctation; however, these procedures are not feasible or desirable in all patients, and long-term outcome data are not available [19,20]. However, the high percentage of aortic arch hypoplasia, adjacency of the aortic arch to the area of recoarctation, calcification in the area of previous correction as well as the use of small diameter grafts, their pronounced lengthening and deformity may be regarded as contraindications for stenting.

The main indications for aortoaortic bypass grafting from the ascending to the descending thoracic aorta for coarctation and recoarctation are:

* the high probability of left common carotid artery clamping in case of low brain ischemia tolerance,
* tubular hypoplasia of the aortic arch,
* calcification of the distal segment of the aortic arch and isthmus,
* abnormalities of the aortic arch with aberrant diversion of the aortic branches.

There are few long-term reports of bypass grafting for coarctation or recoarctation. Potential long-term complications include graft narrowing with thrombus and neointimal formation. Additional potential late complications include infection, development of false aneurysms, and anastomotic dehiscence with pseudoaneurysm formation in patients who have considerable somatic growth after repair. None of the patients that we have reported required reoperation for graft-related complications at a mean follow-up of 6.5 years.

So, aortoaortic bypass grafting is a safer and less invasive procedure as compared to the existent types of direct and bypass operations for it allows us:

1. to avoid the risks linked with rethoracotomy (injury to the lungs, intercostal arteries, aorta, recurrent laryngeal nerve),
2. to avoid the risks related to the clamping of the aortic walls changed by dysplasia and degeneration at the site of previous correction,
3. to minimize the risk of acute disorders of central hemodynamics and spinal complications because of the probability of parietal retraction of the aorta,
4. to avoid the use of hypothermia and cardiopulmonary bypass.


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

1. Aortoaortic bypass grafting from the ascending to the descending thoracic aorta does not require labor-consuming and cumbersome techniques for protection of the spinal cord and visceral organs and excludes the difficulties of the left-sided rethoracotomy.
2. Aortoaortic bypass grafting is a safer, less invasive and effective method for correction of the complicated forms of aortic coarctation and recoarctation syndrome.


   Footnotes
 
{star} Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.

1 Tel.: +7 95 414 75 51; fax: +7 95 414 78 67. Back


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

  1. Berdat PA, Göber V, Carrel T. Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults. Interact Cardiovasc Thorac Surg 2003;2:133-137.[Abstract/Free Full Text]
  2. Amato JJ, Douglas WI, James T, Desai U. Coarctation of the aorta. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2000;3:125-141.[Medline]
  3. Daebritz S, Fausten B, Sachweh J, Muhler E, Franke A, Messmer BJ. Anatomically positioned aorta ascending–descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999;16:519-523.[Abstract/Free Full Text]
  4. Magee AG, Brzezinska-Rajszys G, Qureshi SA, Rosenthal E, Zubrzycka M, Ksiazyk J, Tynan M. Stent implantation for aortic coarctation and recoarctation. Heart 1999;82:600-606.[Abstract/Free Full Text]
  5. Heinemann MK, Ziemer G, Wahlers T, Kohler A, Borst HG. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur J Cardiothorac Surg 1997;11:169-175.[Abstract]
  6. 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.[Abstract/Free Full Text]
  7. Connolly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;104:I133-I137.[Medline]
  8. Ralph-Edwards AC, Williams WG, Coles JC, Rebeyka IM, Trusler GA, Freedom RM. Reoperation for recurrent aortic coarctation. Ann Thorac Surg 1995;60:1303-1307.[Abstract/Free Full Text]
  9. Beekman RH, Rocchini AP, Behrendt DM, Rosental A. Re-operation for coarctation of the aorta. Am J Cardiol 1981;48:1108-1114.[CrossRef][Medline]
  10. Messmer BJ, 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]
  11. Zehr KJ, Gillinov AM, Redmond JM, Greene PS, Kan JS, Gardner TJ, Reitz BA. 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]
  12. Grinda J, Mace L, Dervanian P, Folliguet T, Neveux J. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg 1995;60:1299-1302.[Abstract/Free Full Text]
  13. Weldon CS, Hartmann Jr AF, Steinhoff NG, Morrissey JD. A simple, safe, and rapid technique for the management of recurrent coarctation of the aorta. Ann Thorac Surg 1973;15:510-519.[Medline]
  14. Clagett OT, Jampolis RW. Coarctation of the aorta. Arch Surg 1951;63:337-348.
  15. Sweeney M, Walker W, Duncan J, Hallman G, Livesay J, Cooley D. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1985;40:46-49.[Abstract]
  16. Edie R, Janani J, Attai L, Malm J, Robinson G. Bypass grafts for recurrent or complex coarctation of the aorta. Ann Thorac Surg 1975;20:558-566.[Abstract]
  17. 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]
  18. Vijayanagar R, Natarajan P, Eckstein P, Bognolo D, Toole J. 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.[Abstract]
  19. Hijazi ZM, Fahley JT, Kleinman CS, Hellenbrand WE. Balloon angioplasty for recurrent coarctation of aorta, immediate and long-term results. Circulation 1991;84:1150-1156.[Abstract/Free Full Text]
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