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Thoracic and Cardiovascular Surgery Department, University of Paris VI Pierre et Marie, Groupe Hospitalier Pitie-Salpêtrière, Assistance Publique – Hôpitaux de Paris, 47-83, Boulevard de l’Hôpital, 75651 Paris Cedex 13, France
Received 13 January 2008; received in revised form 18 June 2008; accepted 19 June 2008.
* Corresponding author. Tel.: +33 1 42 16 56 09; fax: +33 1 42 16 56 39. (Email: beltranlevy{at}hotmail.com).
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Abstract |
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 Top Abstract 1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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Key Words: Coarctation • Reoperation • Adult
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1. Introduction |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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Recurrent coarctation of the aorta is a more challenging problem. The classical surgical options including resection with direct end-to-end anastomosis, patch aortoplasty, or interposition tube grafts will require re-entering the left chest to expose previously operated aortic segments with adhesion, instauration of cardiopulmonary bypass (CPB) and aortic cross-clamping with its inherent risk of bleeding, injury of adjacent nerves and paraplegia due to abnormal collateral circulation and spinal cord ischemic insult [2–4]. Extra-anatomic aortic bypass through the mid-line, however, avoids local dissection of previously operated zone and cross-clamping of the aortic arch. In this report, we present our experience with ascending-to-abdominal aorta extra-anatomic bypass, for recurrent aortic coarctation in adults.
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2. Material and methods |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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All data are presented as mean ± standard deviation.
They were 10 males and 2 females. Their mean age was 36.2 ± 11.3 (range 21–57) years old. Mean age at primary repair was 14.3 ± 4.2 years old (range 8–21). All patients presented arterial hypertension. All but two presented diminished femoral pulse, and one patient had total abolition of femoral pulse. A murmur was present in 10 patients. Mean left ventricle ejection fraction was 60 ± 12% (range 37–70). Half of the patients were in NYHA class I and the other 50% were in class II.
Six patients (cases 3, 4, 5, 6, 8, 12) presented concomitant cardiac pathologies: aortic valve insufficiencies [3], ascending aorta aneurysms [2], one patient had an aortic valve stenosis and a right coronary artery stenosis. One patient presented with acute aortic valve infectious endocarditis 3 months before surgery (case 8). Patient characteristics are summarized in Table 1 .
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3. Surgical technique |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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Following these principles, surgery is performed via median sternotomy extended into the epigastrium with a supra-umbilical laparotomy through the mid-line abdominal fascia. To expose the supra-celiac abdominal segment of the aorta between the pillars of the diaphragm, the transverse colon and the big curve of the stomach are retracted downward and the triangular ligament of the left hepatic lobe is divided to mobilize the liver to the right. After systemic heparinization (1 mg/kg) the abdominal aorta is partially side-clamped and an end-to-side anastomosis with a Dacron® graft (diameter 20–22 mm) is performed (Fig. 1 ). After local control for hemostasis, the graft is passed through an incision made on the fibrous part of the diaphragm and positioned along the inferior aspect of the right ventricle and lateral to the right atrium to the reach the right aspect of the ascending aorta. A 25–30 cm graft length is usually adequate in most adults. After side-clamping the ascending aorta, the proximal end-to-side anastomosis is performed; then the graft is de-aired and de-clamped (Fig. 2 ). The operation is finished with closing of the chest and abdomen in the standard fashion. In case of the need to implant the graft on the distal segments of the aorta (infrarenal aorta or iliac arteries), a full mid-line laparotomy is performed, and the graft is passed behind or through the mesenteric root and in front of the pancreas.
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Concomitant procedures were needed in six patients, all of them required CPB: four aortic valve replacements (AVR) one of them associated to a right coronary artery bypass graft and two supra-coronary ascending aorta graft replacements.
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4. Results |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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Mean stay time in intensive care unit for all patients excluding patient 12 was 67 ± 32 h (range 24–96).
Follow-up was completed by the end of February 2007. Two patients were lost to follow-up. Both patients moved overseas soon after surgery.
For the 10 other patients mean follow-up time was 124 ± 111 months (range 4 months to 27.8 years). No patient had any graft-related complication or death and all grafts were patent at the end of the follow-up period. One patient developed dilated cardiomyopathy and was entered in the transplant waiting list, dying at 14 years of follow-up due to congestive heart failure while on the waiting list.
In four patients arterial hypertension (AHT) persisted after surgery which was well controlled by one medication treatment. The remaining five patients are asymptomatic (Table 2 ).
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5. Discussion |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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Percutaneous balloon dilation would be one of the treatment options in this situation [7,8]; however, when extensive calcification of the previous operated area exists, this option may be precluded.
Surgical options by direct approach include: resection of the narrowed segment and tube graft replacement, patch graft aortoplasty or subclavian artery patch [2,3,9,10]; all of which require a redo left thoracotomy, dissection of the previous operative site and, eventually in case of difficulty, the instauration of cardiopulmonary bypass and deep hypothermic circulatory arrest with an increasing risk for bleeding, paraplegia, recurrent laryngeal and phrenic nerves injury and pulmonary tissue injury.
Paraplegia is the most devastating complication. The real incidence is difficult to discern from the literature, but reported rate is about 2.6% [4]. Paraplegia occurs due to an ischemic insult to the spinal cord when a cross-clamp is applied to the descending aorta. Shunts, CPB, hypothermic cardiopulmonary arrest and left heart bypass are used to avoid spinal cord ischemic insult [2–4,10]. However, all these techniques have morbidity on their own.
Another way is to avoid reopening the left chest and to perform an extra-anatomic bypass graft. There are various reports with extra-anatomical aortic bypass for recurrent aortic coarctation. Most of these reported series require institution of CPB or re-entering the left chest [11–16]. In the posterior pericardial approach technique [14–16] the authors had to use CPB in all cases to retract the heart cephalad to abort the retro-pericardial portion of the thoracic descending aorta. In their series, Caspi et al. [13] and Aralkelyan et al. [12] utilized a right thoracotomy to perform the bypass avoiding the already operated zone. Even though it is a simple technique that does not need the instauration of CPB, it does not solve the whole spectrum of concomitant cardiac pathology. In our experience, ascending-to-abdominal aorta bypass through a median sternotomy and upper mid-line laparotomy is recommended because it avoids the utilization of CPB, cross-clamping of the thoracic descending aorta and dissection of a heavily scarred zone of the previous operation; thus, the risk of damaging of nerves structures and/or the friable aortic wall and important collaterals which be inaccessible in the adherent tissue (with its inherent potential hemorrhagic complication) is minimized; reducing at the same time, the risk of ischemic injury of the spinal cord.
This surgical approach gives an excellent exposure of the ascending aorta and the heart allowing concomitant cardiac and/or ascending aorta pathology surgery, which is quite frequent in this group of patients.
Reported mortality for direct repair of recoarctation varies from 0% to 8% [2,3,10]. In this series there were no postoperative deaths. Although the present work presents a small number of patients, its mortality and morbidity rates compares favorably [11,12,14].
Reported morbidity rates for direct repair of recoarctation is as high as 50% [3,10]. Ralph-Edwards et al. [3] in a series of 43 patients, who underwent reoperation for coarctation of the aorta, described a 4.7% rate of recurrent laryngeal nerve palsy, 2.3% rate of phrenic nerve palsy and 7% rate of postoperative bleeding requiring reoperation. In the present series only two patients presented a major postoperative complication. One morganella related pulmonary infection which responded favorably to antibiotic treatment, and a cardiac arrest, related to a coronary artery bypass graft kinking. No patient had any neurological complication.
Another issue concerning these patients is the concomitant cardiac pathology. Of interest, due to its frequency and surgical implications in adult patients, are bicuspid aortic valve and ascending aortic aneurysm.
A bicuspid aortic valve is found in 20–85% of patients [5,17–20], significant stenosis and/or regurgitation develops in up to 65% of the cases [18], of whom at least 7–10% [17] will require aortic valve replacement. Roos-Hesselink et al. [21] in a series of 124 patients operated for coarctation of the aorta, found that 28% of the patients presented a dilated ascending thoracic aorta and 63% developed aortic valve disease in the follow-up, of whom up one third needed aortic valve intervention. Similarly in a previous report from our institution, Mesnildrey et al. [22] in a series of 27 adult patients (35-year old or over) with coarctation of the aorta, found that 37% presented an associated cardiopathy, of whom 40% presented an aortic valve pathology.
In the present series, six patients (50%) presented at the time of reoperation with either isolated aortic valve insufficiency (n = 3), aortic valve stenosis (n = 1) or aneurysm of the ascending thoracic aorta (n = 2). With this in mind the preoperative assessment is vital in this kind of patient, in order to plan the best surgical strategy.
This is a retrospective series of patients over a long study period spanning 27 years (1979–2006). This time frame coincides with the evolution of imaging means of assessment; while in early years cardiac catheterization and aortography were the modalities of choice, today imaging has shifted toward the use of less invasive techniques: two-dimension echocardiography with color Doppler, MRI and CT-scan.
Transthoracic echocardiography is used for the initial assessment, since it provides a comprehensive assessment of valvular and ventricular function in addition to a reliable assessment of the pressure gradient across the recoarctation site, which could be completed with transesophageal echocardiography as needed [23].
High-resolution images of the entire aorta, including the recoarctation site, can be obtained by MRI and CT-scan [24,25], which provide detailed anatomic information for the planning of surgery.
Although is a small series, the results in the long-term are very good, as in the other papers cited in the literature [12,13]. There were no graft-related complications or death during the follow-up period (ranging from 4 months to 27 years). Nine patients were alive. One patient died at 14 years of follow-up, he developed a dilated cardiomyopathy dying while he was on the transplant waiting list.
The main clinical feature was persistence of arterial hypertension [3,6], which in this report accounts up to 30% and was well managed with one drug therapy in all patients.
In conclusion recoarctation of the aorta in adult patient population is a complex entity. Associated cardiac pathologies are common. Preoperative assessment is of vital importance in order to draw the best surgical strategy.
Ascending-to-abdominal aorta extra-anatomic bypass with Dacron® grafts through a median sternotomy and mid-line upper laparotomy approach is a safe, effective and less invasive technique for repairing aortic recoarctation in adults.
This technique allows performing the correction of the eventually concomitant cardiac pathology. It presents good results in the long-term.
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Acknowledgments |
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References |
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TopAbstract1. Introduction2. Material and methods3. Surgical technique4. Results5. DiscussionReferences |
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