Ann Thorac Surg 2002;73:278-280
© 2002 The Society of Thoracic Surgeons
Case report
Antero-axillary access for hypoplastic aortic arch repair
Sandra Fraund, MD*a,
Andreas Böning, MDa,
Jens Scheewe, MDa,
Jochen T. Cremer, MDa
a Department for Cardiovascular Surgery, University of Kiel, Kiel, Germany
Accepted for publication April 17, 2001.
* Address reprint requests to Dr Fraund, Department for Cardiovascular Surgery, University of Kiel, Arnold-Heller-Strasse 7, 24105 Kiel, Germany
e-mail: sfraund{at}kielheart-uni-kiel.de
 |
Abstract
|
|---|
A 16-year-old adolescent presented with systemic hypertension due to a hypoplasia of the aortic arch resulting in a significant stenosis. In childhood, he underwent surgery for aortic coarctation through a left posterolateral thoracotomy. We present the successful repair of the complete aortic arch that could be achieved applying a patch plasty of bovine pericardium through an antero-axillary thoracotomy.
|
Introduction
|
|---|
Poor growth and underdevelopment of the aortic arch are frequently associated with coarctation. As the potential of the aortic growth decreases progressively after birth, an early correction of coarctation seems to be important allowing for a compensatory development of the transverse aorta [1]. Usually aortic arch repair is performed by median sternotomy. The case of a 16-year-old boy suffering from functional aortic arch stenosis is described. Successful repair of the aortic arch was performed inserting a bovine pericardial patch in deep hypothermic circulatory arrest through an antero-axillary thoracotomy.
A 16-year-old boy presented with arterial hypertension and progressive exhaustion. At the age of 3, the boy had undergone surgery for aortic coarctation and closure of a ductus arteriosus, which was performed in a standard fashion through a left posterolateral thoracotomy by use of an end-to-end anastomosis technique. Following resection of the stenotic segment, a postoperative angiography confirmed a good surgical result and showed a moderately hypoplastic distal arch with nearly half the size diameter as the descending aorta. At the age of 8 years, restenosis at the previous corrected coarctation site was echocardiographically suspected, but cardiac catheterization revealed a hypoplastic aortic arch beginning at the brachiocephalic trunk and ending at the coarctation repair site with a gradient of 30 to 35 mm Hg. At this time, the patient had a regular blood pressure and normal physical condition. In 24-hour pressure measurements half a year later, increased systolic and diastolic pressures with reduced circadian rhythm was detected. Therefore, medical treatment with a beta-blocker was started. Due to the meanwhile reduced physical condition, a cardiac catheterization was repeated at the age of 16 assessing an increase of the gradient to over 40 mm Hg along the aortic arch as a result of a hypoplastic segment with only 8 mm in diameter between the brachiocephalic trunk and the left subclavian artery (Fig 1).
As a percutaneous angioplasty (PTA) maneuver of the hypoplastic segment failed, surgical treatment was proposed.
View larger version (173K):
[in this window]
[in a new window]
|
Fig 1. Preoperative angiography demonstrating a hypoplastic segment of the aortic arch with only 8-mm diameter, resulting in a gradient of 40 mm Hg along the aortic arch.
|
|
On admission, physical examination revealed a normally developed young man with a strong right radial pulse, whereas the pulses of the lower extremities were comparably weak. There was a grade II/VI ejection systolic murmur in the left parasternal area above the second to third intercostal space. A computerized tomographic scan of the chest showed no pathologies other than the known aortic hypoplasia.
First, the left groin was prepared for subsequent venous cannulation, then a left antero-axillary thoracotomy in the third intercostal space was performed (Fig 2).
As expected from the computerized tomographic scan, the aortic arch and branches were located very apically. They were extensively dissected, but access especially to the posterior part of the aorta was significantly impaired by adhesions. Then, the ascending aorta was prepared for cannulation, and the left vagal and recurrent nerve were isolated and encircled. During preparation of extensive scars around the descending aorta, an incidental injury of the aortic wall occurred, requiring immediate cardiopulmonary bypass after heparinization. The patient was cooled down to a lowest nasopharyngeal temperature of 17.8°C. During cooling, the preparation was completed, and the aortic wall was repaired with a few singular stitches. After reaching profound hypothermia, the head vessels were snared and total circulatory arrest was induced. A suitably tailored bovine pericardial patch was inserted following a longitudinal incision of the aortic arch. After completion of arch repair, retrograde deairing was performed first; after removing the clamp from the ascending aorta, cardiopulmonary bypass was restarted, head vessel snares were removed, and the patient was rewarmed. For ventricular fibrillation, repeated defibrillation after opening of the pericardium was necessary. Cardiopulmonary bypass time was 139 minutes with a circulatory arrest of 39 minutes. Before closure of the chest, invasive arterial pressure measurements in ascending aorta and femoral artery revealed a mean gradient of 2 mm Hg, confirming an effective repair. The postoperative course was uneventful. Before discharge, magnetic-resonance angiography was performed and showed a satisfying result (Fig 3).
The young patient went home on the 8th postoperative day.
|
Comment
|
|---|
The incidence of a hypoplastic aortic arch in infants with coarctation is 25% to 50%. Usually there is no need for surgical arch enlargement except for particular anatomic conditions. It could be shown that a moderately hypoplastic arch will regularly develop with compensatory growth when coarctation is successfully repaired in early infancy [2].
In our case, coarctation was repaired at the age of 3 years resulting in a reduced growth potential of the aortic arch. The definition of a hypoplastic aortic arch is made by the ratio of ascending aorta to transverse arch less than 0.5 [3]. In our patient, ascending aorta was 16.6 mm, descending aorta was 14 mm, and arch stenosis measured 8.3 mm revealing a ratio of 0.5. As our patient suffered from complaint associated with hypertension unresponsive to medical treatment and increased exercise exhaustion, the indication for surgical correction was given. One option for repair would have been the implantation of a prosthetic bypass between the ascending and descending aorta. This technique has been described by Daebritz and colleagues in 5 patients with nondilatable hypoplastic arch segments after coarctation repair in childhood [4].
The technical features of such an approach included 18 to 20 mm Dacron (C. R. Bard, Haverhill, MA) bypass parallel to the anatomic arch by use of partial clamping of the ascending aorta and without cardiopulmonary bypass via the left posterior thoracotomy. To obtain a more anatomical reconstruction of the aortic arch in the young and maybe still growing patient, we decided for an arch repair. As proven by various groups, a central neurological complication rate below 5% can be achieved in elective arch surgery by use of deep hypothermia and circulatory arrest [5]. Comparing different approaches of aortic arch surgery including moderate hypothermia with selective cerebral arterial perfusion, continued distal perfusion, or retrograde cerebral perfusion, we decided for hypothermic cardiopulmonary arrest, which appeared in this case a safe and effective option, as we expected an acceptably short arrest time. For reconstruction of the hypoplastic vessel segment, we selected a bovine pericardium instead of the stiffer Dacron or polytetrafluoroethylene patches assuming superior quality with respect to ease of handling, hemostasis, and lack of subsequent aneurysmal degeneration. It has been shown by different authors using bovine pericardium in carotid surgery, or as patch graft angioplasties, that this material seems to be a good alternative as vascular graft material in arterial surgery with encouraging long-term results [6, 7].
Usually in small infants, a hypoplastic or interrupted aortic arch is corrected via sternotomy [8]. But this access might create major difficulties in adolescent patients especially in the setting of reoperation due to the limited access to proximal descending aorta. Derived from preoperative magnetic resonance imaging and computed tomographic imaging, we expected a narrow arch segment, a cranially distracted distal arch, and major adhesions around the previous coarctation repair through a left posterolateral thoracotomy. Thus, a repeat left posterolateral thoracotomy also was not preferred, as suboptimal access to the arch was anticipated with this approach. Instead, we decided to use an antero-axillary thoracotomy, a technique which is established as a standardized approach in lung surgery and has been introduced by Walterbusch and associates in 1994 for aortic surgery [9]. Different authors, like Sasaguri and colleagues, recommend this incision for aortic arch surgery combining the advantages of an isolated sternotomy and a posterolateral thoracotomy with optimal control of the aortic arch [10]. Another advantage of this incision is the minimum of muscle division, keeping the latissimus dorsi and trapezius muscles preserved compared with the standard lateral thoracotomy, and keeping the upper arm–shoulder belt unextended in contrast to a regular sternotomy. Our patient could be operated on safely, managed with superior exposure of the ascending aorta for clamping and evenly satisfying access to the posterior part of the aortic arch, so that reconstruction of the hypoplastic segment could be successfully performed with a bovine pericardial patch. Also, using this access, injury of the left recurrent laryngeal nerve and phrenic nerve could be avoided by the superior exposition, resulting in normal nerve function postoperatively.
The patient recovered quickly from the surgical trauma and could be discharged home after an uneventful course of 8 postoperative days. Therefore, we recommend strongly the antero-axillary approach for the repair of a hypoplastic aortic arch in adolescents or adults, especially when surgical demands increase due to previous surgery performed through a midsternotomy or posterolateral thoracotomy.
|
References
|
|---|
-
Kopf G.S., Hellenbrand W., Kleinmann C., Lister G., Talner N., Laks H. Repair of coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41:425-430.[Abstract]
-
Siewers R.D., Ettedgui J., Pahl E., Tallman T., del Nido P.J. Coarctation and hypoplasia of the aortic arch: will the arch grow?. Ann Thorac Surg 1991;52:608-614.[Abstract]
-
Moulaert A.J., Bruins C.C., Oppenheimer-Dekker A. Anomalies of the aortic arch and ventricular septal defects. Circulation 1976;53:1011-1015.[Abstract/Free Full Text]
-
Daebritz S., Fausten B., Sachweh J., Muhler E., Franke A., Messmer B.J. Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999;16:519-523.[Abstract/Free Full Text]
-
Coselli J.S., Büket S., Djukanovic B. Aortic arch operation: current treatment and results. Ann Thorac Surg 1995;59:19-27.[Abstract/Free Full Text]
-
Biasi G.M., Mingazzini P., Baronio L., Sampaolo A. Processed bovine pericardium as patch angioplasty for carotid endarterectomy: a preliminary report. Cardiovasc Surg 1996;4:848-852.[Medline]
-
Araujo J.D., Braile D.M., Azenha Filho J.O., Barros E.T., Marconi A. The use of bovine pericardium as an arterial graft. A 5-year follow-up. J Cardiovasc Surg (Torino) 1987;28:434-439.[Medline]
-
Karl T.R., Sano S., Brawn W., Mee R.B. Repair of hypoplastic or interrupted aortic arch via sternotomy. J Thorac Cardiovasc Surg 1992;104:688-695.[Abstract]
-
Walterbusch G., Marr U., Abramov V., Frömke J. The antero-axillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta. Eur J Cardiothorac Surg 1994;8:79-81.[Abstract]
-
Sasaguri S., Yamamoto S., Fukuda T., Hosoda Y. Retrograde cerebral perfusion through antero-axillary thoracotomy in the aortic arch surgery. Eur J Cardiothorac Surg 1997;11:657-660.[Abstract]
Top
Abstract
Introduction
