Ann Thorac Surg 2004;78:e58-e60
© 2004 The Society of Thoracic Surgeons
How to do it
Median sternotomy for reoperation of the distal aortic arch in postcoarctectomy patients
Joris W. J. Vriend, MDa,
Barbara J. M. Mulder, MD, PhDa,
Paul H. Schoof, MD, PhDb,
Mark G. Hazekamp, MD, PhDb,*
a Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
b Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
Accepted for publication March 30, 2004.
* Address reprint requests to Dr Hazekamp, Department of Cardiothoracic Surgery, Leiden University Medical Center Leiden, PO Box 9600, 2300 RC Leiden, the Netherlands
m.g.hazekamp{at}lumc.nl
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Abstract
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We report the usefulness of a median sternotomy approach for the surgical treatment of residual aortic gradients or recoarctation and aortic aneurysms. This series confirms that excellent surgical results can be obtained in this technically challenging group of patients needing postcoarctation repair.
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Introduction
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Residual aortic gradients or recoarctation and aortic aneurysms are well-known complications after surgical repair of aortic coarctation that often require reintervention. Left thoracotomy for reoperation of the aortic arch is complicated by poor exposure of the proximal arch, multiple adhesions, and a marked difficulty in repairing associated or residual intracardiac lesions [1]. Furthermore, a left thoracotomy approach may be unsafe if brachiocephalic arteries need to be clamped. In this brief report we discuss our experience using a median sternotomy approach for redo surgery in adolescent and adult postcoarctectomy patients with complex residual aortic gradients or aortic arch aneurysms.
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Technique
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Thirteen postcoarctectomy patients (8 male and 5 female patients, aged 14 to 38 years) underwent reoperation for recoarctation, hypoplastic aortic arch, or aortic arch aneurysm at our clinics between December 1994 and December 2003. Age at the initial coarctation repair ranged from 3 days to 18 years. All patients had a left thoracotomy. In 3 patients a persistent arterial duct was also ligated at initial repair. Type of coarctation repair, indications for reoperation, and type of reoperation are shown in Table 1. Median time between the initial coarctation repair and reoperation was 23 years (range 13 to 37 years). All patients were hypertensive before reoperation and were taking antihypertensive medications. A median sternotomy approach was used in all patients. Hypothermic cardiopulmonary bypass was established in 11 patients after aortic and right atrial cannulation; in 2 patients a femorofemoral bypass was used. Mean cardiopulmonary bypass time was 195 ± 53 minutes (range 115 to 295 minutes). Aortic cross-clamping was used in 11 procedures (median 71 minutes, range 32 to 203 minutes). Total circulatory arrest was necessary in 5 procedures for a median of 29 minutes (range 20 to 48 minutes). In 8 patients circulatory arrest with selective antegrade cerebral perfusion was used (median 53 minutes, range 22 to 83 minutes). In 2 patients associated intracardiac procedures were performed (Table 1).
No early or late mortalities occurred. Postoperative hoarseness developed in 4 patients (one of which was only temporarily) because of recurrent laryngeal nerve paralysis. Mediastinitis requiring prolonged antibiotic treatment developed in 1 patient. Patients were followed for a mean duration of 3.0 years (range 20 days to 8.5 years). Six patients remained hypertensive after reoperation. All patients underwent postoperative assessment with echocardiography and magnetic resonance imaging of the aorta within 2 to 3 years after redo surgery. In all patients satisfying results were obtained. None of the patients had a significant arm-leg difference in blood pressure measurement (at least 20 mm Hg). In none of the patients was diastolic antegrade flow in the descending aorta ("saw tooth"-phenomenon) encountered at echocardiography; no significant residual aortic stenosis or aortic aneurysms were found at magnetic resonance imaging.
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Comment
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This series confirms that excellent surgical results can be obtained in the technically challenging group of patients needing postcoarctation repair. Median sternotomy can achieve extensive mobilization of the thoracic aorta, an important achievement considering that many residual aortic arch obstructions are located in the arch itself and not only at the site of the initial coarctation repair. By this approach the whole aortic arch and descending aorta can be reached at a level more caudal than the carina. Retraction of the left main bronchus is usually the limiting factor. Furthermore, median sternotomy approach allows not only repair of hypoplasia of the transverse aortic arch (Fig 1) and distal aortic arch aneurysms (Fig 2), but also repair of frequently coexisting cardiac anomalies.
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Fig 2. Magnetic resonance angiogram of patient number 6. An aneurysm of the ascending aorta and hypoplastic aortic arch is visible.
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The risk of recoarctation after operation is known to increase with repair in early infancy. Recently, however, a prevalence of residual obstruction of only 5.5% was reported in patients who underwent repair during the neonatal period (younger than 1 month of age) at a median postoperative follow-up of 2 years [2]. The risk of recoarctation after initial surgical repair is most often seen when simple end-to-end anastomosis and subclavian flap repair techniques are used [3]. Balloon angioplasty with or without stent implantation is now a widely accepted therapeutic procedure for aortic recoarctation. Nevertheless, although most patients undergoing percutaneous balloon angioplasty for recoarctation will achieve long-term benefit, the need for further surgical intervention in patients with transverse arch hypoplasia was reported to remain high [4].
Aortic aneurysm formation is another indication for reoperation in postcoarctectomy patients. Despite primary success, aortic (pseudo)aneurysms at or near the site of repair develop in 9% of patients late after operation with aortic rupture; a lethal outcome has been reported in some [5]. The risk of aneurysm formation of the distal aortic arch seems highest after subclavian flap and patch graft repairs, whereas end-to-end anastomosis carries the lowest risk of aortic aneurysmal formation (3%). Advanced age at coarctation repair and transverse aortic arch hypoplasia are other risk factors associated with aortic aneurysm formation [5, 6].
Thus, late complications requiring reintervention after primary surgical or transcatheter intervention for aortic coarctation will develop in a subset of patients. Repair of the distal aortic arch can be performed by patch aortoplasty or tube graft interposition. Although patch augmentation may be technically easier to perform in selected cases, limitation of the use of synthetic patch aortoplasty is in general mandatory because of the risk of aneurysm formation. Whereas many patients with recoarctation will be suitable candidates for transcatheter treatment, complex anatomy, aortic aneurysm formation, or associated cardiac disease may favor a surgical approach. Median sternotomy for reoperation of postcoarctectomy patients can be performed—as also shown by the results of our study—with low morbidity and mortality [7].
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References
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- Bogaert J, Gewillig M, Rademakers F, et al. Transverse arch hypoplasia predisposes to aneurysm formation at the repair site after patch angioplasty for coarctation of the aorta. J Am Coll Cardiol. 1995;26:521–527[Abstract]
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Abstract
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