Ann Thorac Surg 2003;76:1728-1730
© 2003 The Society of Thoracic Surgeons
Case report
New "right side median" approach for postoperative re-coarctation of the aorta
Takeshi Shinkawa, MDa,
Masaaki Yamagishi, MD*a,
Keisuke Shuntoh, MDa,
Tsutomu Matsushita, MDa,
Katsuji Fujiwara, MDa,
Nobuo Kitamura, MDa
a Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
Accepted for publication March 28, 2003.
* Address reprint requests to Dr Yamagishi, Department of Pediatric Cardiovascular Surgery, Children’s Research Hospital, Kyoto Prefectural University of Medicine, Kawaramachi, Hirokoji, Kamikyo-ku, Kyoto 602-8566, Japan
e-mail: myama{at}koto.kpu-m.ac.jp
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Abstract
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Anatomic repair of postoperative recurrent coarctation of the aorta is surgically difficult using the conventional lateral approach. Therefore, we have developed a new approach to the stenotic aorta through a median sternotomy, involving division of the superior vena cava and left caudal displacement of the heart. This approach facilitates extensive dissection and mobilization of the descending aorta in the posterior mediastinum behind the heart and also facilitates direct anastomosis of the aortic arch and the descending aorta after resection of the stenosis. This approach is useful for anatomic repair of postoperative recurrent coarctation of the aorta and other posterior mediastinal procedures.
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Introduction
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Although recurrent aortic stenosis after repair of the coarctation or interruption of the aorta requires surgical reintervention, extensive dissection and mobilization of both the aortic arch and the descending aorta are difficult using conventional lateral or median approaches. To address this problem, we developed a new approach to facilitate extensive dissection and mobilization of the descending aorta behind the heart through a median sternotomy. Using this approach, recurrent aortic stenosis was successfully reconstructed without any prosthetic material.
A 13-day-old boy who was diagnosed with type A interruption of the aorta and ventricular septal defect underwent aortic arch reconstruction by end-to-end anastomosis and pulmonary artery banding through a left thoracotomy. Two months after the operation, balloon angioplasty for aortic stenosis at the anastomosis was required. At 3 months of age, he underwent closure of the ventricular septal defect and de-banding of the pulmonary artery through a median sternotomy. Recurrent aortic stenosis was dominant at 9 months of age. The difference in blood pressure between the upper and lower body was 40 mm Hg. Because repeated balloon angioplasty was not effective, he was referred to our hospital for surgical reintervention for the aorta. An echocardiogram showed residual ventricular septal defect, and a magnetic resonance angiogram showed severe aortic stenosis and narrowing of the left subclavian artery (Fig 1A).
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Fig 1. (A) Preoperative magnetic resonance angiogram showing severe stenosis of the distal aortic arch and narrowing of the left subclavian artery. (B) Postoperative magnetic resonance angiogram showing smooth continuity of the aortic arch with no narrowing.
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Surgical reintervention was performed at 1 year, 9 months of age with a body weight of 9.7 kg. Through repeated median sternotomy, the ascending aorta, neck arteries, superior vena cava, both pulmonary arteries, and right pulmonary veins were dissected and mobilized. The aortic arch was also dissected as far distal as possible from the midline, but extensive dissection of the descending aorta in the posterior mediastinum behind the heart was impossible. Arterial cannulas were inserted into the ascending aorta, the left common carotid artery, and the descending aorta just above the diaphragm, and venous cannulas were inserted into both venae cava. A moderate hypothermic cardiopulmonary bypass was established. After transection of the superior vena cava at the level of the right pulmonary artery, the heart was left caudally overturned. The descending aorta in the posterior mediastinum behind the heart was dissected and exposed through the space between the ascending aorta, the right pulmonary artery, and the left atrial roof. Extensive dissection and mobilization of the descending aorta was easily accomplished through the right side of the descending aorta (the "right side median" approach) (Figs 2A, 2B).
All intercostal arteries were preserved. The aortic arch, left subclavian artery, and descending aorta were clamped, and the thickened and stenotic aortic wall was removed. The aorta was reconstructed by direct anastomosis. The descending aorta and the anastomosis site were not under tension because the descending aorta had been extensively mobilized. The superior vena cava was repaired by direct end-to-end anastomosis after closure of the residual ventricular septal defect (Fig 2C). No prosthetic material was used.
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Fig 2. (A) Operative view of the "right side median" approach. The descending aorta was easily exposed and mobilized from the right side of the aorta with the division of the superior vena cava and left caudal overturn of the heart. The white arrow indicates the site of stenosis and the black arrow indicates the distal stump of the superior vena cava. (B) Surgeon’s view of the right side median approach. The descending aorta was extensively dissected and mobilized. (C) Operative view after anatomic repair. The white arrow indicates the aortic anastomosis site and the black arrow indicates the repaired superior vena cava. (aAo = ascending aorta; BCA = brachiocephalic artery; dAo = descending aorta; LA = left atrium; MPA = main pulmonary artery; RBr = right bronchus; RPA = right pulmonary artery; RUPVs = right upper pulmonary veins; SVC = superior vena cava).
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A postoperative 3-dimensional computed tomographic scan showed no stenotic lesion of the repaired superior vena cava, and a postoperative magnetic resonance angiogram showed smooth continuity of the aortic arch and descending aorta with no narrowing (Fig 1B).
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Comment
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The operation for postoperative recurrent aortic stenosis is still surgically challenging, and various operative techniques have been reported [1, 2]. Extra-anatomic repair using a prosthetic graft in pediatric patients is associated with complications and should only be performed when absolutely necessary [3], but anatomic repair with autologous aortic wall requires extensive dissection and mobilization of both the aortic arch and the descending aorta.
Extensive dissection of both the aortic arch and the descending aorta through the conventional lateral approach is very difficult, because the tight pleural adhesion can lead to parenchymal lung injury, recurrent nerve injury, and massive bleeding from collateral vessels. It is difficult to establish a cardiopulmonary bypass through the lateral approach in children, and it may cause ischemic injury of the spinal cord or other lower body organs.
To overcome these problems of reoperation for recurrent aortic stenosis, we have developed a new right side median approach through a median sternotomy. This approach involves application of the "overturn" approach we have previously reported [4]. With the division of the superior vena cava and left caudal overturn of the heart, the descending aorta in the posterior mediastinum behind the heart is easily dissected and mobilized through the space between the ascending aorta, the right pulmonary artery, and the left atrial roof. This approach provides wide exposure of the posterior mediastinum and makes it possible to mobilize the descending aorta extensively without any difficulties or complications.
The right side median approach is useful not only for the anatomic repair of postoperative recurrent aortic stenosis, it is also applicable to other posterior mediastinal lesions such as unifocalization of major aortopulmonary collateral arteries.
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References
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- Sweeney M.S., Walker W.E., Duncan J.M., Hallman G.L., Livesay J.J., Cooley D.A. Reoperation for aortic coarctation: techniques, results, and indications for various approaches. Ann Thorac Surg 1985;40:46-49.[Abstract]
- Foster E.D. Reoperation for aortic coarctation. Ann Thorac Surg 1984;38:81-89.[Abstract]
- Izhar U., Hartzell V., Mullany C.J., Daly R.C., Orszulak T.A. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000;70:31-37.[Abstract/Free Full Text]
- Yamagishi M, Shuntoh K, Matsushita T, et al. Complete augmentation of diffuse narrowing of the aorta with Williams syndrome by an overturn approach. J Thorac Cardiovasc Surg 2003;125:1556–8
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Abstract
Introduction
