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Ann Thorac Surg 1995;60:1299-1302
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Bypass Graft for Complex Forms of Isthmic Aortic Coarctation in Adults

Department of Cardiovascular and Pediatric Cardiac Surgery, Marie Lannelongue Hospital, Le Plessis-Robinson, and Paris Sud University, Paris, France

Accepted for publication June 5, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Bypass grafting for complex forms of coarctation has been poorly documented as an alternative to decrease the high complication rate associated with anatomic repair.

Methods. Between mid-1980 and the end of 1994, 16 patients underwent bypass grafting for complex forms of isthmic aortic coarctation. Age ranged from 11 to 49 years (mean age, 28.4 ± 13 years). Indications were atypical anatomic forms of coarctation (n = 12) and reoperation after multiple or complicated previous coarctation repair (n = 4). Lateroisthmic bypass grafts were performed in 14 patients and ascending aorta–descending aorta bypass grafts in 2.

Results. There was no hospital mortality. Morbidity consisted of postoperative paradoxical hypertension in 3 patients. There were no spinal cord complications. One death 10 years postoperatively was unrelated to the surgical technique. One patient successfully underwent ascending aorta–descending aorta bypass grafting for a false aneurysm 10 years after lateroisthmic grafting. All patients were asymptomatic and all grafts, patent after a mean follow-up of 5.7 ± 4 years.

Conclusions. On the basis of these results, bypass grafting appears to be a safe alternative in this select group of patients. The lateroisthmic bypass graft is the procedure of first choice, and the ascending aorta–descending aorta bypass graft should be reserved for failure of previous lateroisthmic bypass grafting.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Since the first successful repair of aortic coarctation [1], treatment of simple forms is now well established. However, despite a 50-year experience, surgical repair of coarctation remains a technical challenge in the subset of older patients with atypical anatomic forms of coarctation: long coarctation, aortic wall calcifications, extensive or minimal collateral circulation, and multiple previous operations. These patients are exposed to major operative risks with use of the various surgical anatomic techniques involving direct exposure of the diseased aorta: end-to-end anastomosis, subclavian flap aortoplasty, subclavian displacement, prosthetic patch aortoplasty, or prosthetic patch interposition grafting. Specific risks are linked either to the dissection of the aortic and periaortic structures or to spinal cord ischemia associated with total aortic cross-clamping.

To minimize these drawbacks in this subset of patients, we propose the use of a bypass graft, either a lateroisthmic bypass graft (subclavian artery–descending aorta or aortic arch–descending aorta bypass graft) or an ascending aorta–descending aorta bypass graft. The purpose of this study was to review our 14-year experience with these procedures and report the early and mid-term results.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From April 1980 to December 1994, bypass grafting was performed in 16 consecutive patients seen with complex forms of isthmic aortic coarctation. There were 11 male and 5 female patients with a mean age of 28.4 ± 13 years (range, 11 to 49 years). All patients except 1 had upper extremity hypertension with systolic blood pressure in the right arm ranging from 150 to 250 mm Hg and diastolic pressure, from 80 to 120 mm Hg. Chest roentgenograms showed definite notching of the ribs in 10 patients, and echocardiograms revealed left ventricular hypertrophy in 9. All patients underwent preoperative angiography to demonstrate the anatomy of the coarctation and to outline the collateral circulation. The aortic systolic gradient across the coarctation ranged from 40 to 115 mm Hg, with a mean systolic gradient for all patients of 60 mm Hg. Associated cardiovascular anomalies included bicuspid aortic valves (n = 3) and an atrial septal defect (n = 1).

Indications for Bypass Grafting
Twelve patients underwent bypass grafting as the initial surgical procedure for atypical anatomic forms of aortic coarctation. Bypass grafting was indicated in the presence of at least one of the following criteria: long coarctation (n = 4), extensive collateral circulation (n = 6), minimal collateral circulation (n = 2), and extensive calcification of the aortic wall (n = 4). Two patients had two criteria (extensive collateral circulation and extensive calcification of the aortic wall) and 1 patient, three criteria (extensive collateral circulation, extensive calcification of the aortic wall, and long coarctation).

In 4 patients, bypass grafting was performed as a reoperation after multiple or complicated previous procedures. Two with a previous anatomic repair received a lateroisthmic bypass graft. In patient 1, recoarctation developed after an end-to-end anastomosis. Intraoperative findings included a long-segment recoarctation with a friable aorta giving off two large intercostal arteries. Patient 2 had undergone an end-to-end anastomosis followed by patch aortoplasty ultimately complicated by a false aneurysm. The 2 other patients had ascending aorta–descending aorta bypass grafting because of failure of a previous bypass graft repair. As a neonate, patient 3 had received an atypical interposition graft, which became restrictive, and patient 4 was seen with occlusion of a lateroisthmic bypass graft.

Operative Technique
Lateroisthmic bypass grafting was performed in 14 patients (Fig 1). A left posterolateral thoracotomy was used in 13 patients. The dissection was limited to the area of the anastomoses. Proximal implantation was done on the left subclavian artery (n = 12) or on the transverse aortic arch in the case of involvement of the subclavian artery (n = 2). Distal implantation was performed on the descending thoracic aorta in all instances. Both proximal and distal end-to-side anastomoses were performed under partial aortic cross-clamping using continuous 5-0 polypropylene suture. In 1 patient, the lesion was approached through a transverse bilateral thoracotomy under cardiopulmonary bypass, as an associated aortic valve commissurotomy was required. The grafts included 16-mm tubular Dacron grafts in 10 patients, tubular Dacron grafts less than 16 mm in diameter in 2 female patients, and tubular Dacron grafts greater than 16 mm in 2 male patients with bicuspid aortic valves.

View larger version (152K): [in this window] [in a new window]   Fig 1. . Postoperative angiogram of subclavian artery-to-descending aorta bypass graft.

View larger version (161K): [in this window] [in a new window]   Fig 2. . Operative view of completed ascending aorta-to-descending aorta bypass graft.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
There were no early deaths. None of the patients required reoperation for bleeding. There was no spinal cord ischemia, no left phrenic or left recurrent laryngeal nerve damage, and no chylothorax. Postoperative paradoxical hypertension occurred in 3 patients within 36 hours after operation. Two had normalization of blood pressure within 2 weeks, and 1 remains hypertensive.

The average stay in the intensive care unit was 2 days (range, 1 to 6 days). In 1 patient, the hospital course was complicated by atrial fibrillation, which was reversed by cardioversion. No abdominal vasculitis was observed. Aortic gradients were obtained in all patients by intraoperative measurement, Doppler study, or both. Gradients ranged from 0 to 35 mm Hg (mean gradient, 5 mm Hg). The average postoperative stay was 14.2 ± 2.6 days (range, 8 to 16 days).

In all patients the preoperatively observed chest wall collateral pulsations disappeared, and upper and lower extremity pulses were equal. The group average blood pressure in the right arm before operation was 179/97 mm Hg, 150/90 mm Hg at discharge from the hospital, and 142/87 mm Hg at follow-up examination. Three patients received antihypertensive therapy, which controlled the hypertension in 2; 1 has persistent hypertension. These 3 patients underwent initial repair of coarctation at a mean age of 41.3 years. Not 1 of the 3 has been seen with recurrent coarctation.

The 6 normotensive patients who underwent exercise testing had normal blood pressure responses and no increase in aortic gradient. Left ventricular hypertrophy regressed in all patients. None of the patients had clinical or echographic signs suggestive of a restrictive graft. In patients evaluated by computed tomographic scan and angiography, graft patency was confirmed. Two patients had a normal pregnancy without any complications. During follow-up, 1 patient required aortic valve replacement with aortic root enlargement 2 years after lateroisthmic bypass grafting.

There have been two late complications. A patient who underwent operation at the age of 28 years and who had persistent hypertension postoperatively died of an intracranial hemorrhage 10 years after operation. One patient required reoperation for an infected false aneurysm of dental origin 10 years after lateroisthmic bypass grafting. This patient underwent ascending aorta–descending aorta bypass grafting through a median sternotomy followed in the same operation by excision of the septic lesion through a separate left thoracotomy.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Adult patients with complex forms of aortic coarctation remain a technical challenge and represent a high-risk group for postoperative mortality and morbidity [2]. In this population, end-to-end anastomosis and even interposition grafting or patch graft aortoplasty have been thought to have a prohibitive risk of intraoperative, postoperative, or long-term complications. Moreover, late mortality is increased by the persistence of hypertension and myocardial hypertrophy, both of which are common in these patients [3, 4]. Consequently, some authors [5] have questioned the benefit of performing any surgical repair in patients older than 40 years.

Surgical intervention in very young or very old patients, reoperations, and associated intracardiac defects increase the risk of death [6–8]. In series involving adult patients, initial operation or reoperation resulted in mortality rates of 5% to 10% [5, 7, 9]. When anatomic repair is used, the increased mortality observed in this subset of patients is related to intraoperative hemorrhage [10]. Other complications such as recurrent laryngeal nerve damage, phrenic nerve paralysis, chylothorax, and intrathoracic sepsis are more frequently encountered when anatomic repair is performed [7, 9, 11]. Paraplegia remains the most feared complication of operation for aortic coarctation. The probability of spinal complications after coarctation repair is 0.5% [2, 6, 10, 12]. Older age is associated with an increased incidence of paraplegia. Lerberg and associates [6] reported an incidence of 5% for patients older than 11 years.

In an attempt to decrease or eliminate these complications of anatomic repair of complex coarctation that are related to direct dissection and total aortic cross-clamping, several technical modifications have been advocated. We focused on the use of bypass grafts and obtained excellent results without any mortality or spinal cord ischemia, as also reported by others [13, 14]. Bypass grafting allows control of situations known to increase the risk of spinal cord injury such as duration and level of total aortic cross-clamping [15], inadequacy of collateral circulation [16], presence of an anomalous right subclavian artery, and a small-gradient coarctation [12, 16]. Moreover, we never had to use one of the numerous methods of spinal cord protection [17].

Our technique of choice is lateroisthmic bypass grafting performed through a left posterolateral thoracotomy and preferably subclavian artery–aorta bypass when possible. When the coarctation extends to the origin of the left subclavian artery, an aortic arch–descending aorta bypass graft is placed. These techniques are simple, safe, and feasible [13, 14].

We use the ascending aorta–descending aorta bypass graft as the method of choice in patients with failure of a previous lateroisthmic bypass graft. The use of the ascending aorta to bypass a complex coarctation has been described previously, and the distal anastomosis has been performed on the descending thoracic aorta or the supraceliac abdominal aorta and even on the infrarenal abdominal aorta or the femoral artery in the case of associated lesions of the abdominal aorta [11, 14, 18, 19]. We perform all distal anastomoses on the descending thoracic aorta through a median sternotomy. Thus we avoid an associated thoracotomy or laparotomy as used by others [13, 19]. We have never performed this procedure through a right thoracotomy, as previously described [20]; it represents a possible third alternative for a future repair. We prefer the midline median sternotomy approach because it is simple and safe, as full control of the aorta is easily established. This approach also causes fewer respiratory complications in patients who have had a previous left thoracotomy. We did not encounter an older patient in whom axillofemoral bypass grafting [21] could have been beneficial.

There are few reports concerning the long-term outcome of bypass grafting for complex forms of coarctation. Potential drawbacks of the use of prosthetic material are thrombosis, infection, and false aneurysm formation. These risks have not been stratified by types of procedure requiring a prosthesis such as bypass grafting, interposition grafting, or patch graft aortoplasty, except for a higher rate of false aneurysm seen with the last technique [22]. Follow-up was longer than 10 years in 5 of our patients. Of the 14 patients undergoing lateroisthmic bypass grafting, only 1 patient required reoperation, which was done 10 years after the initial operation. One patient had reoperation for thrombosis of a lateroisthmic bypass graft placed 33 years earlier in another institution. The use of an ascending aorta–descending aorta bypass graft to manage these 2 patients seen with failure of a previous lateroisthmic bypass graft was successful. Thus, it represents a safe alternative for this complication.

These findings are in agreement with the study of Edie and colleagues [14], who reported good results with a follow-up of 3 months to 11 years. Concerning the ascending aorta–descending aorta bypass graft, our short follow-up does not allow firm conclusions to be drawn. However, there are several reports [18, 19] of excellent results for up to 10 years.

We found bypass grafting to be the procedure of choice in this select group of patients with complex forms of aortic coarctation. We believe that the absence of mortality and the low incidence of morbidity resulted from careful operative technique. Follow-up results at midterm are satisfactory. Long-term evaluation will be mandatory to assess the possible occurrence of specific complications encountered with prosthetic materials. Nevertheless, we have found useful the techniques of lateroisthmic bypass grafting performed through a left thoracotomy to manage anatomically complex forms of coarctation and ascending aorta–descending aorta bypass grafting performed through a sternotomy for reoperation after a previous lateroisthmic bypass graft.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Neveux, Département de Chirurgie Cardiovasculaire et Cardiaque Pediatrique, Hôpital Marie Lannelongue, 133 ave de la Résistance, 92350 Le Plessis Robinson, France.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract 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): Loïc Macé Thierry A. Folliguet Jean-Yves Neveux Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Grinda, J.-M. Articles by Neveux, J.-Y. Search for Related Content PubMed PubMed Citation Articles by Grinda, J.-M. Articles by Neveux, J.-Y.