Eur J Cardiothorac Surg 2007;32:176-177. doi:10.1016/j.ejcts.2007.03.038
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Total arch replacement of late aneurysm after bypass grafting for coarctation of the aorta
Tomoyuki Goto*,
Yasushi Tsutsumi,
Takahiro Kawai,
Hirokazu Ohhashi
Department of Cardiovascular Surgery, Fukui Cardiovascular Center, 2-228 Shinbo, Fukui City, Fukui 910-0833, Japan
Received 15 February 2007;
received in revised form 19 March 2007;
accepted 23 March 2007.
* Corresponding author. Tel.: +81 776 54 5660; fax: +81 776 53 2132. (Email: afuro{at}fc4.so-net.ne.jp).
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Abstract
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We present the case of a 53-year-old man who underwent a total arch replacement for descending thoracic aortic aneurysm of distal anastomosis site after bypass grafting for coarctation of the aorta at 26 years of age.
Key Words: Coarctation • Bypass grafting • Late aneurysm • Total arch replacement
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1. Introduction
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Late aneurysm of the descending thoracic aorta is a well-known postoperative complication of repair of coarctation of the aorta. Almost all such aneurysms occur after prosthetic patch aortoplasty [1,2]. There are only three reports of late aneurysm after bypass grafting [3–5]. We describe the surgical repair of late aneurysm of the descending aorta 27 years after bypass grafting for coarctation.
A 53-year-old man was referred to our hospital because of abnormal mediastinal enlargement (Fig. 1a). He had undergone left subclavian artery-descending aorta bypass with a knitted Dacron graft 8 mm for coarctation of the aorta through a left thoracotomy at another hospital at 26 years of age. Computed tomography of the chest revealed a true aneurysm of the distal anastomosis, which was 55 mm in diameter (Fig. 1b).
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Fig. 1. (a) Preoperative chest X-ray shows an abnormal mediastinal enlargement. (b) Preoperative computed tomography of the chest reveals the distal arch aneurysm, bypass graft from the left subclavian artery to the descending aorta, and the transverse arch hypoplasia.
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During the operation, the aneurysm was approached through the median sternotomy. Adhesions between the previous graft and left lung were severe, but dissection was steadily carried out by a sternal retractor for internal thoracic artery harvesting and an ultrasonically activated scalpel (Harmonic Scalpel; Ultracision Inc., Smithfield, RI). The aneurysm was 57 mm in diameter and derived from the distal end of the bypass graft. The aortic arch was hypoplastic as preoperative computed tomography of the chest showed. The left subclavian artery was originated from the hypoplastic arch, and the brachiocephalic artery and the left carotid artery were originated from a common orifice. For that reason, we selected a total arch replacement. After cardiopulmonary bypass was established with cannulating into the ascending aorta, and into the SVC and the IVC, myocardial protection was achieved using intermittent retrograde cold-blood cardioplegia. The patient was cooled to a core body temperature of 27 °C. After introduction of hypothermic circulatory arrest, the transverse arch was open and selective cerebral perfusion (SCP) was commenced by inserting a 12 Fr SCP balloon-tipped cannula from within the aorta into the brachiocephalic artery, left carotid artery and left suvclavian artery. Total arch replacement was performed using 26 mm Hemashield woven double-velour graft with separated grafting technique (i.e., grafting of the cervical vessels, individually, with quadrifurcated grafts). After distal anastomosis, systemic circulation was resumed using a branch of the arch graft. Systemic ischemic and aortic cross-clamp times were 35 and 100 min.
The postoperative course was uncomplicated, and postoperative computed tomography revealed a patent graft (Fig. 2
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Fig. 2. Postoperative computed tomography demonstrates the removing of the arch aneurysm and a good shape of aortic arch.
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2. Comment
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Aneurysm formation at the site of previous coarctation repair has been reported frequently as a late complication of this condition. von Kodolitsch et al. introduced 9% of such patients developed aortic aneurysms late after the operation [6]. Although only three papers have reported late aneurysm formation after bypass grafting for coarctation [3–5], late aneurysm potentially occurs not only after patch angioplasty, subclavian flap angioplasty, tube graft repair, end-to-end anastomosis, but also after bypass grafting. In addition, Kang et al. reported a high incidence of aneurysm formation after bypass grafting at a median of 6 years postoperatively [5]. Some papers reported extra-anatomic bypass grafting had low incidences of both mortality and morbidity [7,8]. Their follow-up, however, has been short. In point of late aneurysm, we have some misgivings about extra-anatomic bypass grafting.
The pathogenesis of late aneurysm formation after coarctation repair is not clearly understood. Several factors predisposing to aneurysm formation have been proposed, including congenital weakness of the aortic wall, extensive resection of the aortic intima, the presence of ductal tissue in the aortic wall at the repair site, and abnormal tension caused by the rigidity of the prosthetic material against the aortic wall [1,5]. von Kodolitsch et al. reported that use of the patch graft technique and late correction of coarctation (after more than 13.5 years) predispose to aneurysm formation at the site of coarctation repair [6]. In the present case, bypass grafting for coarctation of the aorta was performed at 26 years of age. The aortic wall may weaken as a result of long-term exposure to turbulent blood flow due to coarctation of the aorta. Moreover, abnormal wall tension and turbulent blood flow due to extra-anatomic bypass grafting may predispose the weakened aorta to aneurysm formation.
Therefore, we believe it is important to eliminate the entire weakened aorta for such young adult patients. Kang et al. demonstrated a good result of surgical repair of postcoarctation site aneurysm using circulatory arrest through left thoracotomy [5]. Kazui et al. reported a low mortality and morbidity of total arch replacement for arch aneurysms [9]. Although several reports of endoluminal repair for late aneurysm after coarctation repair showed early good results in a small series [10], this technique has a number of problems. First, for the young age of these patients, the durability of stents remains a concern. No long-term results of endovascular therapy of thoracic aneurysms are available. Second, this technique does not apply to every such patient. For example, if aneurysms involve the left subclavian artery or the left common carotid artery, this technique is not preferable. If there is persistence of transverse arch hypoplasia, this technique has a risk of intraluminal obstruction.
We reported a total arch replacement of late aneurysm after bypass grafting for coarctation of the aorta. We believe that it is essential to remove the whole diseased aorta for such young adult patients, and careful long-term follow-up of patients who have undergone bypass grafting of this type is mandatory, although there are only a few reports of late aneurysm after bypass grafting.
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References
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Abstract
1. Introduction
