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Ann Thorac Surg 1996;62:1511-1513
© 1996 The Society of Thoracic Surgeons

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Case Report

Late True Aneurysm After Bypass Grafting for Long Aortic Coarctation

First Department of Surgery, Osaka University Medical School, Osaka, Japan

Accepted for publication May 20, 1996.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Two adolescent patients who underwent a repair of long aortic coarctation using bypass grafting with subsequent late true aneurysm formation are reported. To our knowledge, only 1 case of late true aneurysm formation after bypass grafting has been reported in the English-language literature.

	Introduction

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It has been reported that a bypass graft is the procedure of choice in patients with complex forms of aortic coarctation, such as long coarctation [1–4]. Although late true aneurysm formation has been well known after prosthetic patch aortoplasty [5–9], only 1 instance of such a complication has been reported after bypass grafting [10]. We report 2 patients with true aneurysm of the descending aorta 13 and 16 years after repair of a long aortic coarctation using a bypass graft in adolescence.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
A 16-year-old girl was referred because of a bruit in her back and a systolic pressure gradient of 36 mm Hg between her upper and lower extremities. Aortic angiography revealed long aortic coarctation. She underwent transverse aortic arch–descending aorta bypass with a 14-mm knitted Dacron graft through the left posterolateral thoracotomy. The coarctation was postductal and 10 cm in length. Both proximal and distal end-to-side anastomoses were performed under partial aortic cross-clamping using continuous 3-0 polypropylene suture. The diameters of the proximal and distal anastomoses were 22 mm and 15 mm, respectively. At 24 years of age, she had false aneurysm at the proximal anastomosis and underwent patch closure of the laceration on the suture lines through a left posterolateral thoracotomy.

At 32 years of age, follow-up computed tomography of the chest showed an aneurysm of the distal anastomosis (Fig 1). She underwent graft replacement of the aneurysm through a left posterolateral thoracotomy. The aneurysm was found to be a 57 x 67-mm true aneurysm and derived from the distal end of the bypass graft (Fig 2A). After cross-clamping of the distal ends of the aortic isthmus and the graft and the descending aorta 10 mm distal to the end of the aneurysm, the aneurysm was resected and replaced by a 20-mm Hemashield graft (Meadox Medicals, Oakland, NJ) under femoral artery–femoral vein perfusion (Fig 2B). The aortic wall pieces around the origins of the eighth and ninth intercostal arteries were anastomosed to the graft to prevent spinal cord injury. The operation was performed without transfusion.

View larger version (139K): [in this window] [in a new window]   Fig 1. . Computed tomogram of the chest of patient 1 (32-year-old woman) showing the aortic aneurysm distal to the bypass graft.

View larger version (54K): [in this window] [in a new window]   Fig 2. . Operative findings of the aorta in patient 1 (32-year-old woman) before (A) and after (B) the repair of the aortic aneurysm.

Patient 2
A 13-year-old boy was referred because of hypertension and a systolic pressure gradient of 55 mm Hg between the upper and lower extremities. Aortic angiography revealed long aortic coarctation from the origin of the left carotid artery to the postductal descending aorta. He underwent ascending aorta–descending aorta bypass with a 10-mm woven Dacron graft through a median sternotomy. The coarctation was 7 mm in diameter and 5 cm in length from the aortic arch distal to the origin of the left carotid artery. Both proximal and distal end-to-side anastomoses were performed under partial aortic cross-clamping using continuous 3-0 polypropylene suture. The diameters of the proximal and distal anastomoses were 24 mm and 20 mm, respectively.

At 28 years of age, the patient was re-referred because of dullness of both lower legs. Chest roentgenography showed enlargement of the left mediastinum. Angiography of the aorta showed a true aneurysm of the descending aorta with a diameter of 35 mm at the distal end of the bypass graft and no blood flow in the graft (Fig 3).

View larger version (155K): [in this window] [in a new window]   Fig 3. . Aortic angiogram of patient 2 (28-year-old man) showing the aortic aneurysm distal to the ascending aorta–descending aorta graft, which was patent.

View larger version (51K): [in this window] [in a new window]   Fig 4. . Operative findings of the aorta in patient 2 (28-year-old man) before (A) and after (B) the repair of the aortic aneurysm.

	Comment

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Older patients with atypical anatomic forms of aortic coarctation have 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, prosthetic patch aortoplasty, or prosthetic interposition grafting [1]. Thus, many authors [1–4] have proposed the use of a bypass graft, either a lateroisthmic bypass graft or an ascending aorta–descending aorta bypass graft. They reported low incidences of both mortality and morbidity, such as spinal cord complications and hemorrhage. There are a few reports concerning the long-term outcome of bypass grafting for complex forms of aortic coarctation. Potential drawbacks of the use of prosthetic material are thrombosis, infection, and aneurysm formation. Although late true aneurysm formation is well known after prosthetic patch aortoplasty, to our knowledge, only 1 case of such complication after bypass grafting has been reported. The first case showed a very large intercostal aneurysm after bypass grafting for aortic coarctation [10]. The aneurysm intraoperatively turned out to be the enlarged blind sac of the aorta distal to the coarctation. The technique of reoperation and the histologic findings of the aneurysmal wall were not documented. Another patient was reported to have an infected false aneurysm of dental origin 10 years after lateroisthmic bypass grafting and 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 [1].

Although late true aneurysm formation occasionally occurs after prosthetic patch aortoplasty, the pathogenesis is not clearly understood. Several mechanisms have been proposed as responsible factors, 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 [5–9]. In the present 2 cases, the graft bypass was anastomosed to the descending aorta far enough from the aortic isthmus to avoid anastomosing the graft at the ductal tissue when the primary bypass grafting was done. Thus, abnormal wall tension caused by compliance mismatch between the prosthetic graft and the aortic wall may be an important etiologic factor in aneurysm formation in the present cases. In the second case, the occlusion of the bypass graft may be also an important factor.

We reported 2 patients with true aortic aneurysm after bypass grafting for long aortic coarctation. Although there is a very low incidence of true aneurysm formation after bypass grafting, careful long-term surveillance is warranted.

	Footnotes

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Address reprint requests to Dr Matsuda, First Department of Surgery, Osaka University Medical School, 2-2 Yamada-oka, Suita, Osaka 565, Japan.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Grinda JM, Mace L, Dervanian P, Folliguet TA, Neveux JY. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg 1995;60:1299–302.[Abstract/Free Full Text]
2. Weldon CS, Hartmann AF Jr, Steinhoff NG, Morrissey JD. A simple safe, and rapid technique for the management of recurrent coarctation of the aorta. Ann Thorac Surg 1973;15:510–9.[Abstract/Free Full Text]
3. Jacob T, Cobanoglu A, Starr A. Late results of ascending aorta–descending aorta bypass grafts for recurrent coarctation of aorta. J Thorac Cardiovasc Surg 1988;95:782–7.[Abstract]
4. Palatianos GM, Kaiser GA, Thurer RJ, Garcia O. Changing trends in the surgical treatment of coarctation of the aorta. Ann Thorac Surg 1985;40:41–5.[Abstract/Free Full Text]
5. Ala-Kulju K, Jarvinen A, Maamies T, Mattila S, Merikallio E. Late aneurysms after patch aortoplasty for coarctation of the aorta in adults. Thorac Cardiovasc Surg 1983;31:301–5.[Medline]
6. Del Nido PJ, Williams WG, Wilson GJ, et al. Synthetic patch angioplasty for repair of coarctation of the aorta: experience with aneurysm formation. Circulation 1986;74(Suppl 1):32–6.
7. Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysms after patch aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92:226–30.[Abstract]
8. McGoldrick JP, Brown MB, Ross DN. Coarctation of aorta: late aneurysm formation with Dacron onlay patch grafting. Ann Thorac Surg 1988;45:89–90.[Abstract/Free Full Text]
9. Ala-Kulju K, Heikkinen L. Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management. Ann Thorac Surg 1989;47:853–6.[Abstract/Free Full Text]
10. Aebert H, Laas J, Bednarski P, Koch U, Prokop M, Borst HG. High incidence of aneurysm formation following patch plasty repair of coarctation. Eur J Cardiothorac Surg 1993;7:200–4.[Abstract/Free Full Text]

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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): Norihide Fukushima Hiroshi Imagawa Hikaru Matsuda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fujita, T. Articles by Matsuda, H. Search for Related Content PubMed PubMed Citation Articles by Fujita, T. Articles by Matsuda, H.