Ann Thorac Surg 2002;73:1678-1680
© 2002 The Society of Thoracic Surgeons
Our surgical heritage
Aortic coarctation reconstructed by resection and homograft replacement in the 1950s: long-term outcome 40 years after operation
Tivadar Hüttl, MD, PhDa,
György Balázs, MDb,
László Entz, MD, PhDa,
Kálmán Hüttl, MD, PhDa,
Elek Bodor, MD, PhDa,
Zoltán Szabolcs, MD, PhD*a
a Cardiovascular Surgical Department, Semmelweis University Hungary
b Department of Radiology, Heim Pál Childrens Hospital, Budapest, Hungary
* Address reprint requests to Dr Szabolcs, Cardiovascular Surgical Department, Semmelweis University, H-1122 Budapest, Városmajor utca 68, Hungary
e-mail: szabzol{at}webmail.hu
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Abstract
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Since the first successful repair of aortic coarctation by Dr Clarence Crafoord in 1945, there are few data regarding late follow-up of homografts in this position. Between 1957 and 1959, 7 patients underwent surgical correction of aortic coarctation by Professor József Kudász at the Department of Cardiovascular Surgery, Semmelweis University, using freeze-dried aortic homograft. We were able to locate 4 of these patients and found no significant complications due to the operation. We report on this 40-year follow-up of implanted aortic homograft.
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Introduction
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In the early era of surgery of aortic coarctation [1], long-segment narrowing was either left untreated or managed with the insertion of homografts [2]. This was indeed the practice of our Department in the 1950s. With development of prosthetic vascular grafts, the application of homologous tissue virtually ceased in the management of different forms of vascular disease. During the past decade, however, there appears to be a "comeback" of homologous arteries into the armamentarium of the vascular surgeon. Because of this, we thought it appropriate to present the late results of some of our patients whose aortic coarctation we had treated with resection and homograft replacement almost 5 decades ago.
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Patients and methods
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Between 1957 and 1959, Professor József Kudász treated 7 patients (age 10 to 31 years, male/female: 4/3) for long aortic coarctations by allograft interposition grafts. The homograft conduits were obtained from cadaver thoracic aortas, explanted within 12 hours postmortem. The grafts were sterilized with antibiotics (penicillin and tetracycline), bathed in the patient’s own sera for a period of 12 hours, then freeze-dried. The operation consisted of thoracotomy in the fourth intercostal space, resection of the involved aortic segment, and replacement with the homograft bathed in physiologic saline, using 3-0 running silk sutures (Fig 1). All patients left the department after uneventful postoperative courses.
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Fig 1. Original photo from 1957 shows the aortic coarctation reconstructed by resection and homograft implantation. Arrow indicates proximal anastomosis.
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Results
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With extensive
search, we were able to locate 5 of the 7 patients. The data of the operated patients are shown in Table 1.
One patient died 13 years after the operation following an unknown general surgical intervention. Four of the patients are alive and doing seemingly well, however, 3 out of 4 still have moderately elevated systolic pressures. Two patients have acceptable systolic pressure differences between the upper and the lower extremities up to 40 to 45 mm Hg, as justified by invasive measurement (Fig 2). Two of the 4 patients agreed to undergo echocardiography, angiography, computer tomography, or magnetic resonance imaging. These studies showed evident signs of calcifications in the homograft wall but unobstructed distal aortic arches (Fig 3).
A small aneurysm in the proximal suture line was identified in 1 patient (Fig 4).
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Fig 2. (A,B) Forty and 45 mm Hg intraaortic systolic pressure gradient in the descending aorta is shown at 43 and 44 years after homograft implantation (cases 6 and 7).
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Fig 3. Control computed tomography performed in September 2001 shows an evident, but not severe, sign of calcification in the homograft wall at 44 years after the operation (case 7). Aortic coarctation was reconstructed by resection and homograft implantation in 1957.
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Fig 4. Control angiography (September 2001) shows a small aneurysm formation in the proximal suture line (arrow), otherwise a normal anatomic situation at 43 years after homograft implantation (case 6).
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Comment
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In this brief communication, we present some clinical observations after insertion of an allograft in the human aorta [3] and long-term observations of using allografts to repair coarctations. With the reintroduction of homografts in vascular surgical practice, these findings support the use of homografts for aortic replacement, especially in cases where there is an infection [4].
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References
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Crafoord C., Nylin G. Congenital coarctation of the aorta and its surgical management. J Thorac Surg 1945;14:347-361.
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Gross R.E., Hurwitt E.S., Bill A.H.A., Jr, Pierce E.C., II Preliminary observations on the use of blood vessel grafts/human/in the treatment of certain cardiovascular defects. N Engl J Med 1948;239:578-579.[Medline]
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Cornelissen P.H.J., Hamerlijnck R.P., Vemeulen F.E. Aneurismatic dilatation of an aortic homograft more than 30 years after implantation into the thoracic aorta. Eur J Cardiothorac Surg 1994;8:447-448.[Abstract/Free Full Text]
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Von Segesser L.K., Vogt P., Genoni M., et al. The infected aorta. J Card Surg 1997;12(Suppl 2):256.[Medline]
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Abstract
Introduction
