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Ann Thorac Surg 1996;61:935-939
© 1996 The Society of Thoracic Surgeons
Kiev Institute of Cardiovascular Surgery of the Academy of Medical Sciences of Ukraine, Kiev, Ukraine
Accepted for publication November 29, 1995.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. Reoperation included aneurysm resection, which was performed in 30 patients (62.5%), followed by prosthetic graft replacement (n = 19), synthetic patch aortoplasty (n = 6), aneurysmorrhaphy (n = 3), or prosthetic bypass graft (n = 2).
Results. Four (13.8%) patients died after reoperation. All 18 patients who were not reoperated on died of a ruptured aortic aneurysm 7 to 15 years after repair of coarctation of the aorta.
Conclusions. With the aim to prevent aneurysm development at the site of coarctation of the aorta repair, severe limitation of indications for synthetic patch aortoplasty is necessary. It can be used only in adult patients with a not too big narrowing. Patients after primary correction of coarctation of the aorta must avoid strenuous physical activity. Chest roentgenography should be performed in these patients each year, and each year they have to be seen by a cardiac surgeon. Suspicion of aneurysm development demands hospitalization, aortography, and reoperation. Preference is given to prosthetic graft replacement using an approach through the left fourth intercostal space with distal circulatory support by means of temporary bypass shunting. Infected aneurysms can be primarily bypassed through the right anterior thoracotomy with the creation of permanent bypass with the help of a vascular graft between the ascending and descending thoracic aorta.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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shows the age of the patients at the time of CA repair and the various operative techniques used. Of these patients, 48 (5.4%) had development of aortic aneurysms at the site of CA repair 1 to 24 years later. Among them 34 (70.8%) were male and 14 (28.2%) female, ranging in age from 1 to 49 years (mean age, 30.9 years).
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) was found in 45 patients. Three patients with recurrent hemoptysis had a normal chest roentgenogram, and 2 of them also had an unremarkable aortogram. However, recurrent hemoptysis and a subfebrile temperature inclined us to the diagnosis of aortic aneurysm. Exploration after entering the left pleural cavity through a fourth intercostal space thoracotomy in 3 of these patients revealed a false aneurysm of a suture line at the site of synthetic patch aortoplasty (SPA).
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). In 4 of 333 patients (1.2%) an aneurysm developed after primary ``end-to-end'' anastomosis. This method was more frequently used in children less than 10 years of age. One of 32 patients (3.1%) had aortic aneurysm after coarctectomy with prosthetic graft replacement.
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). Aneurysms were seen in only 6 patients within 5 years after the operation; 32 (66.7%) of 48 aneurysms were noted during 6 to 16 years of follow-up. In 4 patients aneurysms developed after a strenuous physical effort. Number of observations and time of follow-up permitted us to perform actuarial analysis of frequency of aneurysms appearing from 9 up to 20 years after patch aortoplasty and up to 15 years after other methods of correction. (Fig 3).
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Study of the protocols of operations of CA correction and comparison with the operative findings during reoperation with histologic and microbiological investigations of the nidus of the aortic lesion showed the following: true aortic aneurysms on the wall opposite to the patch were found in 6 observations and, obviously, their development was connected with an excessive excision of the intima at the site of the coarctational diaphragm. Causes of false aneurysm formation with a partial patch tear in 7 patients were the following: thinning of the aortic wall with signs of early atherosclerosis (n = 3); use of an unjustifiably large patch, taking into consideration the child's growth (n = 6), and infection (n = 2). In the remaining patients, the cause of aneurysm formation was not established. It is worth mentioning that in all observations the SPA of the aortic isthmus was performed with the help of flaps of a woven Dacron vascular graft using for sutures threads of Lavsan (Obyiedinenie ``Sever,'' St. Petersburg, Russia) or Prolene (Ethicon, Somerville, NJ).
Methods of Reoperation
Back left-sided thoracotomy through the left fourth intercostal space was performed in 28 patients; in 2 cases of gigantic aneurysms the approach was through the fifth intercostal space. Besides that, right anterior thoracotomy with the creation of permanent bypass with the help of a vascular graft was performed as the first stage of the operation in 2 patients: in 1 it was performed because of infection in the left pleural cavity and in the second because of a marked hypoplasia of the descending thoracic aorta. Deflation of the left lung was achieved with the use of a Carlens type (Portex, Keen, NH) or Broncho-Cath tube (Fuji Systems Corp, Tokyo, Japan) to ease separation of lung adhesions. This substantially diminished the risk of lung trauma and heart compression. Control of the aorta proximal to an aneurysm was performed with the help of an umbilical tape around the aorta and with the help of a clamp placed on the transverse aorta distal to the left common carotid artery and on the left subclavian artery. The left vagus and phrenicus nerves were identified during this and were gently elevated with the help of a rubber tape. Umbilical tape and a clamp were also placed on the descending thoracic aorta immediately below an aneurysm.
Distal Circulatory Support
Distal circulatory support was used in 28 patients: in 17 of them bypass with the help of a vascular graft 10 to 12 mm in diameter between the ascending and descending aorta was performed with this aim, and in 11 patients distal circulatory support was accomplished using a 10-mm-diameter Tygon tube (Morton Texas Medical products, Houston, TX) (Fig 4). During this procedure heparin, 1 mg/kg of body weight, was used; that practically did not increase bleeding and at the same time maintained temporary shunts fully opened. Measurement of pressure in the proximal and distal thoracic aorta during aortic cross-clamping showed neither hypertension in the proximal nor hypotension in its distal part. For example, the mean blood pressure proximal to the cross-clamp was 140 mm Hg, and the distal pressure was 65 mm Hg.
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Aneurysm Correction
After the removal of a thrombotic mass from the aneurysmatic sac, of a patch, of a graft, or of changed aortic wall, repair of the aorta was performed: replacement of a damaged segment of the aorta with the help of a vascular graft (n = 19) or patch plasty of the aorta using a flap of woven vascular graft (n = 6). In 2 patients with small and technically easy false aneurysms aortorrhaphy was performed with short (15 to 20 minutes) aortic cross-clamping without the use of bypass shunting or other types of distal circulatory support.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Postoperative complications included paresis of the left recurrent (n = 4; 13.1%) or left phrenic nerve (n = 2; 6.6%) and bleeding that necessitated a rethoracotomy (n = 1; 3.3%). None of the patients had any spinal cord or kidney complications.
All 18 patients with aneurysms who were not reoperated on died of hemorrhage 7 to 15 years after the repair of the CA. In 16 of these, the CA was repaired by SPA, in 1 primary vascular graft replacement was performed, and in another 1 CA was corrected by coarctectomy and end-to-end anastomosis. The reasons why these patients were not reoperated on were lack of timely diagnosis of an aneurysm (n = 13), reluctance to follow-up (n = 4), and sepsis with purulent disintegration of an aneurysm at the site of SPA (n = 1).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Aneurysm formation in the aortic isthmus after repair of the coarctation may be preconditioned by congenital (thinning or cystic medionecrosis) or acquired (atherosclerosis) changes of the aortic wall, as well as altered hemodynamics (hypertension or blood flow turbulence) [1, 5, 6, 9]. Aneurysm can also be attributed to excessive excision of coarctation, damage to the intima, and increased aortic wall stress, which is transformed through the rigid patch onto a more elastic compromised aortic wall, opposite to the patch [1, 5, 7]. De Santo and associates [7] proved that damage of the intima and of the subintima during excessive excision of the coarctational membrane is an important fact in the pathogenesis of remote aneurysm formation as it markedly weakens the wall of the aorta. Thus, the use of a patch is not justified if the aortic wall is thin or atherosclerotic. Hemodynamically, a rigid synthetic patch may cause dilatation of the more pliable aortic wall [5, 9]. Long-standing hypertension causes additional stress and turbulence at the coarctation repair site. Other possible causes are excessive stress load on the suture line, particularly at the patch angles; suture line dehiscence; wear and fragmentation of the synthetic patch; infection; necrosis of the aorta due to an impaired blood supply from a dissection or an excessive ligation; and trauma from a static work load or exercise [2, 7, 6–12].
It is worth mentioning that the overwhelming majority of our patients with an aneurysm had a normal blood pressure during the entire period of observation after repair of CA. Therefore, we doubt that hypertension alone was a significant factor causing this particular complication.
We noted the highest frequency of aneurysm formation when a synthetic patch was used for correction of the CA. In the majority of patients, this complication had no anatomic or hemodynamic prerequisites. Only in 2 patients was infection a factor. These facts prompted us to be more circumspect when indications were to perform SPA, despite its attractiveness. We came to the conclusion that the use of SPA of the aortic isthmus is possible only in adults whose aortic narrowing is not extensive (its length and perimeter).
Decrease of collateral blood flow, which is observed in the remote period after CA correction, and anatomic and physiologic variation of the spinal cord blood supply make it dangerous to cross-clamp the aorta for more than 30 minutes. Because of that, provision of adequate circulatory support during cross-clamping of the thoracic aorta is important. Different methods have been proposed for this purpose: various types of artificial circulation, external or internal bypass shunting with or without heparinization, hypothermia, and others [13, 14]. We used external bypass shunting; this permitted us to avoid ischemic damage of the spinal cord and kidneys. This method, from our point of view, is simple, reliable, cheap, and sufficiently effective. Recommendations of observation with annual chest roentgenograms and recommendations to avoid strenuous physical effort seem quite warranted. In cases where aneurysm is suspected, aortography is recommended. Elective operation increases the patient's chances to survive. In contrast to this, an urgent operation at the height of bleeding is attended with a high risk of lethal events.
In conclusion, correction of CA with the use of SPA has a substantial risk of aortic aneurysm development, predominantly 6 to 16 years postoperatively. Prevention of aneurysm formation depends on early correction of CA by means of aortoplasty with help of a flap from a subclavian artery or with end-to-end anastomosis. If SPA should be used at all, it is possible only in adults with a short and not too extensive narrowing with absence of marked changes in the aortic wall. Patients after CA correction have to avoid strenous physical activity and should be subjected to life-long medical observation with annual chest roentgenography with careful prophylaxis and timely treatment of infections. Preferable treatment of aortic aneurysms after CA correction is aneurysm resection with vascular graft replacement through a left thoracotomy in the fourth intercostal space using distal circulatory support. Infected aneurysms can be primarily bypassed by right anterior thoracotomy in the fifth intercostal space with creation of a permanent shunt between the ascending and descending thoracic aorta using a vascular graft.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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|
|
|
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|
|
|
|
|
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|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
|
|
E. Rosenthal Stent implantation for aortic coarctation: the treatment of choice in adults? J. Am. Coll. Cardiol., November 1, 2001; 38(5): 1524 - 1527. [Full Text] [PDF]
|
|
|
|
|
|
B. H. Smaill, D. C. McGiffin, I. J. LeGrice, A. A. Young, P. J. Hunter, and A. J. Galbraith The effect of synthetic patch repair of coarctation on regional deformation of the aortic wall J. Thorac. Cardiovasc. Surg., December 1, 2000; 120(6): 1053 - 1063. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. L GIBBS Treatment options for coarctation of the aorta Heart, July 1, 2000; 84(1): 11 - 13. [Full Text]
|
|
|
|
|
|
A G Magee, G Brzezinska-Rajszys, S A Qureshi, E Rosenthal, M Zubrzycka, J Ksiazyk, and M Tynan Stent implantation for aortic coarctation and recoarctation Heart, November 1, 1999; 82(5): 600 - 606. [Abstract] [Full Text]
|
|
|
|
|
|
D. M. Nguyen, J. Tsang, and C. I. Tchervenkov Aneurysm after subclavian flap angioplasty repair of coarctation of the aorta Ann. Thorac. Surg., October 1, 1999; 68(4): 1392 - 1394. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N.P. Jenkins and C. Ward Coarctation of the aorta: natural history and outcome after surgical treatment QJM, July 1, 1999; 92(7): 365 - 371. [Full Text] [PDF]
|
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