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Ann Thorac Surg 2000;70:2153-2154
© 2000 The Society of Thoracic Surgeons

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Case report

Hybrid management of coronary artery disease and coarctation of aorta

^a Department of Surgery, Royal Brompton Hospital, London, England, UK
^b Department of Invasive Cardiology, Royal Brompton Hospital, London, England, UK

Accepted for publication March 20, 2000.

Address reprint requests to Dr Yiu, Department of Surgery, Royal Brompton Hospital, Sydney St, London, England SW3 6NP
e-mail: patrickyiu{at}visto.com

	Abstract

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The treatment of coarctation of aorta with an additional cardiac lesion in adults remains a difficult surgical challenge. We present here an alternative, two-stage, hybrid approach that combined stent repair of aortic coarctation followed by coronary artery bypass operation in an adult with critical coronary lesions and a poor ventricle. This method may be a potentially useful strategy in reducing the comorbidity of operation to both lesions.

	Introduction

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Approximately 10.3% of patients with coarctation of the aorta present after 40 years of age [1]. Among the adult group, the incidence of an additional cardiac disorder (aortic aneurysm, valvular disease, ischemic heart disease) is high [1]. Studies have shown that late repair of coarctation remains worthwhile with regression of presystolic hypertension. However, the strategy for repair of combined lesions presents a difficult surgical challenge.

A 55-year-old man presented with debilitating angina and breathlessness following two myocardial infarctions. Cardiac risk factors included hypertension (blood pressure 150/90 mm Hg) and hypercholesterolemia. Angiography by the femoral approach found a previously undiagnosed coarctation of the aorta. Brachial coronary angiogram showed severe three-vessel disease with an ejection fraction of less than 25%. A thoracic magnetic resonance imaging revealed a membranous coarctation 3 cm distal to the left subclavian artery (with a 2- to 3-mm diameter orifice) and a well-developed collateral circulation. The patient received maximal treatment with aspirin, amlodipine, nicorandil, frusemide, and enalapril. A decision was made to repair both vascular lesions.

A two-stage, hybrid procedure was carried out. The aortic coarctation was first treated by a self-expanding stent. A Brockenbrough transseptal catheter was passed through the inferior vena cava into the right atrium. The interatrial septum was punctured and a guidewire was advanced through the left cardiac chambers into the aortic arch, and fed through the 2- to 3-mm coarctation orifice. This procedure facilitated passage of a second guidewire through the sharply kinked coarctation by a retrograde femoral route. After removing the antegrade guidewire, stenting was carried out retrogradely using a self-expanding 14 x 64 mm Wallstent (Boston Scientific, Natick, MA; Fig 1). The stent was dilated using a 14-mm Mullins high-pressure balloon catheter to a pressure of 8 bar (or 9 atm), which achieved a satisfactory left ventricular-descending aorta gradient of 3 mm Hg (compared with 38 mm Hg before the procedure). The patient was discharged home with clopidogrel 75 mg added to his medications.

View larger version (71K): [in this window] [in a new window]   Fig 1. Aortogram showing hold-up of contrast at the level of coarctation (A). Following stent deployment (B), contrast injection delineated satisfactory stent dilatation of the critical narrowing. Because of the relative undersizing of the Wallstent, the stent was less apposed in the cephalad and caudal aorta. However, this was of no functional significance and the Wallstent had procedural advantages of easier passage through difficult angles and a reduced tendency to migrate compared with some other types of stents.

He remained angina free on follow-up at 6 weeks and was walking more than 2 miles a day. His brachial blood pressure was 100/60 mm Hg and the ankle systolic pressure was 100 mm Hg.

	Comment

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The mortality and morbidity of a staged surgical approach is significant, irrespective of the sequence of repair. Correction of the coarctation alone is associated with increased perioperative myocardial infarction [2]. On the other hand, correction of the cardiac lesion alone is associated with increased postoperative renal failure and paraplegia as a result of inadequate perfusion distal organ perfusion [3]. Consequently, some surgeons advocate simultaneous correction of both pathologies to avoid hemodynamic instability [4]. A combined procedure would typically involve a median sternotomy, establishing cardiopulmonary bypass with right atrial cannulation and double cannulation of the ascending aorta and femoral artery, repair of the cardiac lesion, and concurrent transpericardial ascending aorta to descending thoracic aortic bypass graft. Although a combined approach may overcome some of the unique hemodynamic problems, the increased complexity of the operation adds to operative risks. Our patient had impaired left ventricular ejection fraction and would have poorly tolerated the staged surgical or combined method.

Recent advances in endovascular techniques have enabled nonsurgical treatment of aortic coarctation by balloon dilatation with or without stenting, and created an opportunity for a hybrid procedure. In this regard, we have obtained a good result using such a strategy.

Endovascular stenting of the coarctation in this patient preceded coronary artery bypass operation. An alternative approach, not available to us for logistic reasons, would have been combined stenting and operation within the catheter laboratory. As our patient received aspirin and clopidogrel after stenting, a 4-week gap between stent and operation was considered safer than one of hours or days. Furthermore, recoarctation is a known complication [5]. This complication could have been detected after a 4-week observation period.

Endovascular treatment of aortic coarctation is most often used in young children and the immediate and medium-term results are encouraging [6]. Successful transluminal treatment has also been described in adults [6]. In our case, coarctation was based on a membranous structure and was ideally suited to dilatation. However, adult coarctations are sometimes accompanied by calcifications that complicate interventional procedures. Thus, the skilled methods (which here included transseptal catheter puncture) should be reserved for experienced surgeons. In our patient, combined stent repair and coronary artery bypass operation as a staged procedure tackled a difficult problem and obviated the heightened risks of operation. We propose that, with the rapid expanse of endovascular technology, hybrid approaches can be extremely useful in managing carefully selected patients with complex pathologies and should be considered in centers in which skilled interventional techniques are available.

	References

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1. Liberthson R.R., Pennington D.G., Jacobs M.L., Daggett W.M. Coarctation of the aorta: review of 234 patients and clarification of management problems. Am J Cardiol 1979;43:835-840.[Medline]
2. Pethig K., Wahlers T., Tager S., Borst H.G. Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass. Ann Thorac Surg 1996;61:1724-1726.[Abstract/Free Full Text]
3. Brewer L.A.D., Fosburg R.G., Mulder G.A., Verska J.J. Spinal cord complications following surgery for coarctation of the aorta. A study of 66 cases. J Thorac Cardiovasc Surg 1972;64:368-381.[Medline]
4. Morris R.J., Samuels L.E., Brockman S.K. Total simultaneous repair of coarctation and intracardiac pathology in adult patients. Ann Thorac Surg 1998;65:1698-1702.[Abstract/Free Full Text]
5. Diethrich E.B., Heuser R.R., Cardenas J.R., et al. Endovascular techniques in adult aortic coarctation: the use of stents for native and recurrent coarctation repair. J Endovasc Surg 1995;2:183-188.[Medline]
6. Suarez de Lezo J., Pan M., Romero M., et al. Immediate and follow-up findings after stent treatment for severe coarctation of aorta. Am J Cardiol 1999;83:400-406.[Medline]

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This Article Abstract Full Text (PDF) 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): Patrick Yiu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yiu, P. Articles by Pepper, J. R. Search for Related Content PubMed PubMed Citation Articles by Yiu, P. Articles by Pepper, J. R.