Ann Thorac Surg 2002;74:2047-2050
© 2002 The Society of Thoracic Surgeons
Original article: cardiovascular
Aneurysm formation after patch aortoplasty repair (vossschulte): reoperation in adults with and without hypothermic circulatory arrest
Matthias Roth, MDa*,
Peter Lemke, MDa,
Markus Schönburg, MDa,
Wolf-Peter Klövekorn, MDa,
Erwin P. Bauer, MDa
a Department of Thoracic and Cardiovascular Surgery, Kerckhoff Clinic Foundation, Bad Nauheim, Germany
Accepted for publication June 26, 2002.
* Address reprint requests to Dr Roth, Department of Thoracic and Cardiovascular Surgery, Kerckhoff Clinic Foundation, Benekestrasse 2-8, D-61231 Bad Nauheim, Germany.
e-mail: matthias.roth{at}kerckhoffmed.uni-giessen.de
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Abstract
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BACKGROUND: Aortic aneurysm formation is common after patch aortoplasty repair of coarctation of the aorta. Its incidence varies between 5% and 38%. The majority of patients show progressive aneurysmal dilation within 6 to 18 years and reoperation is necessary to avoid rupture of the aneurysm.
METHODS: Ten patients were reoperated on for patch aneurysm formation. Femorofemoral cardiopulmonary bypass (CPB) with a heparinized system was used in all patients. Decision to initiate hypothermic circulatory arrest (HCA) was made intraoperatively. All patients received a Dacron graft replacement of the aneurysmatic thoracic aorta.
RESULTS: HCA was initiated in 5 patients owing to extreme adhesions in vicinity to the aneurysm. There was no significant intergroup difference regarding time interval after first operation, age, operation time, and postoperative blood loss. Only minor neurologic events were present in 2 patients with cross-clamping the aorta.
CONCLUSIONS: Patch aneurysms after Vossschulte aortoplasty can safely be operated on with femorofemoral CPB. Initiation of HCA is recommended to prevent rupture of the aneurysm during preparation and injury of adjacent nerves and vessels.
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Introduction
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A major long-term complication after Dacron (C.R. Bard, Haverhill, PA) patch repair of coarctation of the aorta is true aneurysm formation. The incidence of this aneurysm formation varies between 5% and 38% [1–3]. The majority of the patients show significant progressive aneurysmal dilation in the region of the aortoplasty within 6 to 18 years [4, 5]. Mostly the surgical preparation in this region is difficult owing to severe adhesions to the surrounding tissues (recurrent nerve, right upper lung). As these aneurysms show markedly thin walls, rupture during preparation is one of the main risks and the use of cardiopulmonary bypass (CPB) is recommended for this type of surgical intervention [1, 6–8]. If cross-clamping of the aortic arch is unsafe or rupture of the aneurysm is expected, hypothermic circulatory arrest (HCA) is the method of choice to avoid bleeding disaster. We report our experience with 10 patients undergoing reoperations for patch aneurysm using CPB with and without HCA.
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Patients and methods
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Patient characteristics are described in Table 1.
All patients had placement of a double-lumen endotracheal tube and were placed in right lateral decubitus position. Transesophageal echocardiography was carried out in all patients to recognize left ventricular distension due to aortic valve insufficiency. Throughout the procedure electroencephalographic monitoring was used. All patients had a proximal and distal pressure line so that the distal arterial pressure could be monitored. The common femoral vein and artery were cannulated (arterial cannula 24F: 3M Sarns, Ann Arbor, MI, with Jostra Bioline Coating; long venous cannula 22F: Jostra, Hirrlingen, Germany, with Bioline coating). When venous return was not satisfactory the pulmonary artery was also cannulated to receive an adequate blood flow. A heparinized hollow fiber membrane oxygenator was used (Quadrox; Jostra, Hirrlingen, Germany, with Bioline coating) and 100 IU heparin per kg body weight was administered to maintain an activated clotting time of at least 180 seconds. During circulatory arrest continuous blood flow was maintained in the oxygenator and the tube system to prevent stasis. If ventricular fibrillation occurred the left atrium was vented. This was the case in all patients with HCA. No aprotinin was used in any case. After termination of ECC heparin was antagonized with protamin sulfate (Protamin; LEO Pharma, Neu-Isenburg, Germany) in a 1:2/3 ratio.
Left posterolateral thoracotomy through the fourth intercostal space was performed. Intrathoracic adhesions were divided so that the left lung could be retracted anteriorly and inferiorly. During this procedure only the right lung was ventilated. If the preparation of the aneurysmatic region could not be done safely or if proximal aortic clamping was impossible the decision to use circulatory arrest was made and the patient was cooled to 18°C. No retrograde cerebral circulation was done. In the remaining patients proximal aortic clamping was possible. After the transverse aortic arch proximal to the left subclavian artery and the descending thoracic aorta had been dissected from their surrounding adventitia, vascular clamps were applied to the aorta. In all cases manipulation of the thin-walled aneurysm was avoided until safe cross-clamping of the aortic arch was possible or the circulation could be arrested. The aneurysm was incised longitudinally (Fig 1A)
and proximal anastomosis to the arch was done with a Dacron tube graft (16 to 24 mm; Dacron Graft Vascutek; Inchinnan, Renfrewshire, Scotland) using 3-0 polypropylene sutures with a strip of polyester felt. In cases with hypothermic circulatory arrest the graft and the distal aorta were clamped and distal anastomosis was completed during rewarming. The patients were brought into the Trendelenburg position during deairing of the aortic arch. The thoracotomy was closed after insertion of chest drains and a catheter for infiltration of local anesthetic agents.
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Fig 1. (A) Intraoperative image of the aneurysmatic aortic wall and the Dacron patch. (B) Intraoperative view of a fusiform aneurysm in the region of the patch aortoplasty. (C) Intraoperative view of two aneurysms in the area of a Dacron patch aortoplasty.
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Results
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There was no early or late mortality (Table 1). In addition, no major perioperative complications such as phrenic nerve injuries, recurrent laryngeal nerve injuries, chylothorax, or spinal cord ischemia were encountered.
Hypothermic circulatory arrest was initiated in 5 patients owing to severe adhesions in the vicinity of the aneurysm (the HCA group; Fig 1B and C). Proximal aortic clamping was possible in 5 patients (the cross-clamping group). There was no significant intergroup (HCA versus cross-clamping) difference regarding the time interval after first operation (24.2 ± 1.5 versus 26.3 ± 3.7 years), age (31.4 ± 3.4 versus 31.8 ± 2.9 years), operation time (330.2 ± 65.2 versus 286.5 ± 81.2 minutes), and postoperative blood loss (864 ± 773 versus 833 ± 462 mL). Cardiopulmonary bypass time was longer (165 ± 18 versus 68.5 ± 30.2 minutes) and rectal temperature lower (15.1 ± 0.8°C versus 29.15 ± 2.9°C) in patients with HCA. Small cerebral infarction with full regression was present in one patient of the cross-clamping group and another patient in the same group suffered from transient aphasia. These neurologic complications may be associated with the retrograde arterial perfusion. One patient in the HCA group had pneumonia of the left upper lobe possibly due to excessive manipulation during preparation. All patients are doing well after a mean follow-up period of 38.2 ± 18.7 months. There was no recurrent aneurysm or dilatation on the site of the repair during follow-up.
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Comment
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The preferred surgical technique for coarctation of the aorta in infants and neonates includes resection of stenotic segments and end-to-end anastomosis of aorta. However, Dacron patch aortoplasty was standard therapy 2 decades ago in some surgical units. Long-term complications after this procedure include persisting hypertension, restenosis, aortobronchial fistula, and aneurysm formation [1, 3].
The incidence of aneurysms after patch aortoplasty is reported to be between 5% [2, 9] and 38% [1, 4, 5]. In a series of 891 patients Knyshov and colleagues [10] found aneurysms in 89.6% of the patients with patch aortoplasty, in 8.3% of the patients with end-to-end anastomosis, and in 2.1% of the patients with a prosthetic graft replacement. Ala-Kulju and Heikkinen [4] reported that 32.8% of patients with patch aortoplasty underwent reoperations because of aneurysm formation opposite or at the site of the patch. The time between primary repair of coarctation and reoperation varies from 6 to 18 years [4, 5]. In our series the time after primary repair was about 25 years.
Persisting hypertension, increased aortic wall-stress opposite the ballooned patch, remaining ductal tissue [8], or extensive resection of intima [11] are supposed to be the main reasons for aneurysm formation, which mostly occurs opposite the patch [12]. DeSanto and coworkers [11] found in animal models that extensive resection of the intima with or without patch angioplasty predisposes to aneurysm formation opposite the aortotomy and should be avoided during coarctation repair.
Owing to the high incidence of aneurysm and aortic rupture [1, 3] controls are mandatory for patients who underwent this procedure (Figs 2 and 3).
Computed tomography and nuclear magnetic resonance imaging have proved to be excellent noninvasive techniques for the diagnosis of patch aneurysm [3]. Indications for operation for an aneurysm after Dacron patch aortoplasty concur with those for other thoracic aneurysms. They should be operated on when the diameter exceeds 50 mm or when rapid enlargement occurs.
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Fig 2. Preoperative magnetic resonance image showing the aneurysm in the area of a Dacron patch aortoplasty.
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Fig 3. Preoperative chest roentgenogram showing the aneurysm in the area of the Dacron patch aortoplasty.
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In general approximately 20% of these patients need reoperation [1]. All patients who were not reoperated on died of a ruptured aortic aneurysm 7 to 15 years after repair of coarctation of the aorta [10]. Different procedures are described for this type of reoperations including prosthetic graft replacement, patch reaortoplasty, or aneurysmorrhaphy. Extra-anatomic bypass grafts of aneurysmal lesions remain an exception [13].
Operative mortality is reported to be between 0% [4] and 13.8% [10] for simple clamping techniques or extra-anatomic bypass graft. Distal circulatory support is recommended by means of temporary bypass shunting or left heart bypass [9, 10]. Lange and colleagues [14] recommended the use of hypothermic circulatory arrest in this special situation. This method allows safe open reconstruction of the descending aorta or the aortic arch. Furthermore there is better protection of the spinal cord. The need for early reoperation because of inadequate repair may be reduced [14]. Szentpetery and associates [15] used partial cardiopulmonary bypass and circulatory arrest as well. They described 14% operative mortality and 14% paraplegia in their series.
As it is well known that the incidence of paraplegia can be significantly reduced by the use of extracorporal circulation, we always perform these operations with partial femorofemoral bypass in order to protect the spinal cord and visceral organs. We could not observe significant differences regarding bleeding or neurologic complications in patients with or without hypothermic circulatory arrest. We think that HCA is indicated when access for proximal control is unsafe due to a large aneurysm or scarring from a previous operation. A distinct additional advantage of HCA is that the scarred tissue at the aortic arch does not have to be completely exposed. This provides protection of the recurrent nerve. The risk of recurrent nerve injury is not insignificant: Bogaert and colleagues [16] and Walterbusch and associates [17] found an injury frequency of 25% and 43%, respectively. Prolonged operation and bypass time as the potential for pulmonary problems or coagulopathy when using HCA are possible disadvantages. Fortunately this was not the case in our patients. We did not see any differences when using HCA. Severe aortic insufficiency is a contraindication for HCA and the left ventricle must be controlled by transesophageal echocardiography.
In conclusion hypothermic circulatory arrest is useful in patients with severe adhesions at the site of the aneurysm to reduce the risk of rupture and injury of adjacent nerves and vessels during preparation. Open proximal anastomosis could be helpful if the distal aortic arch is involved in the aneurysm.
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References
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Abstract
Introduction
