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Ann Thorac Surg 1996;61:241-244
© 1996 The Society of Thoracic Surgeons

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How To Do It

Technique for Extraanatomic Bypass in Complex Aortic Coarctation

Wessex Cardiothoracic Unit, Southampton General Hospital, Southampton, United Kingdom

Accepted for publication September 6, 1995.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
A variety of approaches and surgical techniques have been described for the management of recurrent coarctation. When there is an additional intracardiac defect that requires surgical correction it is preferable to correct both lesions simultaneously and through the same incision. This article reports two new techniques of connecting ascending to descending aorta using an intrathoracic conduit and performed through a median sternotomy.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Surgical correction of recurrent coarctation of the aorta presents a formidable technical challenge. There is no universally accepted surgical procedure, nor is there agreement whether left thoracotomy, median sternotomy, or a combination of the two is the best approach. No single technique is applicable to all patients, and the surgeon must adapt his or her strategy to deal with the specific problems of each case. Choice of operative technique and surgical approach depend on the site of the stenosis, the type of original repair, the degree of mediastinal scarring, and the extent of collateral circulation [1–3].

If recurrent coarctation coexists with intracardiac defects that require surgical correction, then the problem for the surgeon becomes even greater. We describe 2 such cases in which median sternotomy and the institution of cardiopulmonary bypass were necessary to correct intracardiac defects. The recurrent coarctation was corrected by employing two similar methods of extraanatomic bypass completed entirely via a median sternotomy.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
A 5-year-old boy presented with recurrent coarctation and subaortic stenosis. He had originally presented to another institution as a neonate with a type A interrupted aortic arch and a perimembranous ventricular septal defect that was corrected at 3 days of age by means of resection and end-to-end anastomosis via a median sternotomy. A residual coarctation was then repaired at 9 days of age with a subclavian flap angioplasty through a left thoracotomy. Further recurrent coarctation of the distal arch developed, which was treated with balloon dilation on four occasions. At presentation to our unit angiography and magnetic resonance imaging demonstrated severe stenosis of the distal arch extending into the proximal descending thoracic aorta (Fig 1) plus the presence of a subaortic membrane and bicuspid aortic valve creating a gradient of 100 mm Hg across the left ventricular outflow tract.

View larger version (158K): [in this window] [in a new window]   Fig 1. . Coronal magnetic resonance image showing complex coarctation between the ascending aorta (AAO) and descending aorta (DA). The left common carotid artery (LCC) is marked. Note the close relationship of the descending aorta to the left atrium.

View larger version (31K): [in this window] [in a new window]   Fig 2. . Incision through the roof and posterior wall of the left atrium to expose the descending thoracic aorta.

View larger version (152K): [in this window] [in a new window]   Fig 3. . Coronal magnetic resonance image showing the graft (GR) in situ crossing from descending aorta over the roof of the left atrium (LA) and beneath the right pulmonary artery (p) to the ascending aorta.

At operation the median sternotomy wound was reopened and the ascending aorta was found to be of good size at 15 mm diameter, tapering to 5 mm at the distal arch, with dense mediastinal adhesions. Cardiopulmonary bypass was established using bicaval cannulation, the heart was lifted, and the posterior pericardium was incised below the level of the inferior pulmonary veins to expose the descending thoracic aorta. A side-biting clamp was applied and a 12-mm zero-porosity woven Dacron conduit was anastomosed end-to-side using a 5-0 polypropyline suture. The conduit was then passed cranially through the oblique sinus and over the roof of the left atrium to lie beside the ascending aorta (Fig 4). The aorta was then cross-clamped, cardioplegia given, and the left atrium opened. The mitral valve was found to be severely dysplastic such that repair was impossible, and a 23-mm CarboMedics (Austin, TX) mechanical prosthesis was inserted. The left atrium was closed and the proximal conduit was then anastomosed to the right-facing posterior side of the ascending aorta with the cross-clamp still applied. Cardiopulmonary bypass was discontinued with no residual gradient between ascending aorta and the femoral arteries. The patient went on to make a straightforward recovery, being discharged on the fifteenth postoperative day. Follow-up magnetic resonance imaging and Doppler studies showed normal flow in the conduit with no compression of the left atrium or of the conduit itself (Fig 5).

View larger version (66K): [in this window] [in a new window]   Fig 4. . Course of the graft used to bypass the coarctation and its passage through the oblique sinus: (A) posterior view, (B) anterior view.

View larger version (225K): [in this window] [in a new window]   Fig 5. . (A) Coronal magnetic resonance image showing the graft (GR) in the second patient crossing above the roof of the left atrium (LA) and beneath the right pulmonary artery (p) to join the ascending aorta. (B) Origin of the graft from the descending aorta (DA).

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

The two most widely used forms of repair are a patch aortoplasty and a local extraanatomic bypass, both performed via a left thoracotomy [1, 2, 9]. Other well-reported techniques are resection with end-to-end anastomosis or interposition graft. Median sternotomy with cardiopulmonary bypass has been advocated, particularly when coexistent intracardiac abnormalities are present [1, 10, 11]. The use of cardiopulmonary bypass has the added attraction of avoiding the necessity to cross-clamp the aorta at normothermia with the concomitant risk of spinal cord ischemia, particularly if collateral circulation is not well developed [12].

More extensive extraanatomic conduits have occassionally been described. Jacob and associates [4] have reported a series of 10 ascending-descending aortic bypass grafts performed using a combined left thoracotomy (to perform the distal anastamosis) and median sternotomy where the proximal anastomosis is fashioned with a side-biting clamp on the left-facing side of the ascending aorta. A second technique is the ascending-distal abdominal aortic bypass graft described by Siderys and colleagues [13] and subsequently reported in another 4 cases [14, 15] using a single midline incision from suprasternal notch to below the umbilicus. The conduit is passed through a slit made in the center of the diaphragm and brought around the right side of the heart to be anastomosed to the right-facing side of the ascending aorta. This would clearly not be suitable in young children in view of consequent growth.

This article reports a technique in which the recurrent coarctation was successfully bypassed with an entirely intrathoracic conduit through a single incision. Only 4 comparable cases have been reported; these were in an article by Sweeney and associates [1] in which the patients had also required concomitant correction of intracardiac defects. However, in these cases the approach through the posterior wall of the left atrium was not described (patient 1), and in no case was the conduit brought through the oblique sinus (patients 1 and 2).

The pathway of the conduit is clearly shown in Figures 2 and 4. Each of these techniques provides a further option in management of such complex cases while avoiding the requirement for a second surgical incision or extension into the abdomen. The presence of dense fibrosis around the site of previous repair, a long coarcted segment, or poor collateral flow make local bypass procedures or resection difficult and hazardous. Cardiopulmonary bypass allows the heart to be lifted to expose the descending thoracic aorta and reduces the risk of spinal cord ischemia. If mediastinal adhesions prevent complete mobilization of the heart then the descending aorta can be exposed through the posterior wall of the left atrium. The disadvantage of the technique is that it does not provide good access to the descending aorta if there should be bleeding from the distal anastomosis. Fortunately, this did not prove to be a problem in either case, and the use of gelatin-resorcin-formol glue may contribute to decreasing the risk of bleeding.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Mr Barron, Wessex Cardiothoracic Unit, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, United Kingdom.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Sweeney MS, Walker WE, Duncan JM, Hallman GL, Livesay JJ, Cooley DA. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1985;40:46–9.[Abstract/Free Full Text]
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3. Foster ED. Reoperation for aortic coarctation. Ann Thorac Surg 1984;38:81–9.[Abstract/Free Full Text]
4. Jacob T, Cobanoglu A, Starr A. Late results of aorta-descending aorta bypass grafts for recurrent coarctation of the aorta. J Thorac Cardiovasc Surg 1988;95:782–7.[Abstract]
5. Pennington DG, Liberthson RR, Jacobs M. Critical review of experience with surgical repair of coarctation of the aorta. J Thorac Cardiovasc Surg 1979;77:217–22.[Medline]
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7. Van Son JA, Daniels O, Vincent JG, van Lier HJJ, Lacquet LK. Appraisal of resection and end-to-end anastamosis for repair of coarctation of the aorta in infancy: preference for resection. Ann Thorac Surg 1989;48:496–502.[Abstract/Free Full Text]
8. Harlan JL, Doty DB, Brandt B III, Ehrenhaft JL. Coarctation of the aorta in infants. J Thorac Cardiovasc Surg 1984;88:1012–9.[Abstract]
9. Edie RN, Janani J, Attai LA, Malm JR, Robinson G. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg 1975;20:558–66.[Abstract/Free Full Text]
10. Ungerleider RM, Ebert PA. Indications and techniques for midline approach to aortic coarctation in infants and children. Ann Thorac Surg 1987;44:517–22.[Abstract/Free Full Text]
11. DeLeon SY, Downey FX, Baumgartner NE, et al. Transsternal repair of coarctation and associated cardiac defects. Ann Thorac Surg 1994;58:179–84.[Abstract/Free Full Text]
12. Lam CR, Arciniegas E. Surgical management of coarctation of the aorta with minimal collateral circulation. Ann Surg 1973;178:693–7.[Medline]
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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): David J. Barron Robert K. Lamb James L. Monro Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barron, D. J. Articles by Monro, J. L. Search for Related Content PubMed PubMed Citation Articles by Barron, D. J. Articles by Monro, J. L.