Ann Thorac Surg 2004;78:1462-1465
© 2004 The Society of Thoracic Surgeons
Case report
Combined Surgical and Endovascular Approach to Treat a Complex Aortic Coarctation Without Extracorporeal Circulation
Thierry P. Carrel, MDa,*,
Pascal A. Berdat, MDa,
Iris Baumgartner, MDb,
Hans-Peter Dinkel, MDc,
Jürg Schmidli, MDa
a Clinic for Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland,
b Division of Angiology, University Hospital Berne, Berne, Switzerland,
c Division of Radiology, University Hospital Berne, Berne, Switzerland
Accepted for publication July 10, 2003.
* Address reprint requests to Dr Carrel, Clinic for Cardiovascular Surgery, University Hospital Berne, Freiburgstrasse, CH-3010 Berne, Switzerland
thierry.carrel{at}insel.ch
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Abstract
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Various therapeutic approaches have been proposed to treat complex coarctation of the aorta (eg, recoarctation, which requires repetitive interventions, or coarctation with a hypoplastic aortic arch). Resection followed by end-to-end anastomosis or by graft interposition is technically demanding and exposes the patient to considerable perioperative risks. Cardiopulmonary bypass and deep hypothermic circulatory arrest may be necessary to control the distal aortic arch. The role of stent technology in treating this type of lesion has not yet been defined. We present a 21-year-old woman with a recurrent coarctation of the aorta associated with a hypoplastic aortic arch and a pseudoaneurysm of the proximal descending aorta. She had undergone 4 previous interventions. Treatment consisted of a combined surgical and endovascular approach without cardiopulmonary bypass and included extraanatomic aortic bypass, partial debranching of the supraaortic vessels, and stent-graft insertion to exclude the aneurysm.
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Introduction
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Percutaneous balloon dilation with or without stenting is often considered to be the first therapeutic option for simple recoarctation in children and adolescents. However, some complex forms of coarctation (eg, those associated with diffuse hypoplasia of the mid and distal aortic arch and those complicated by a pseudoaneurysm) are not amenable to interventional treatment alone. Surgical treatment may require cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest to completely repair the aortic arch, thus exposing the patient to the risk of cerebrovascular complications [1–4]. My colleagues and I report on a successful combined surgical/endovascular approach that allowed treatment of a recurrent coarctation associated with a tubular hypoplasia of the mid and distal aortic arch and a pseudoaneurysm at the previous site of repair.
A 21-year-old woman presented with severe exercise-induced arterial hypertension of the upper extremities (systolic blood pressure 220 mm Hg); she had experienced headaches for 2 years. Blood pressure at rest was only slightly increased. At the age of 3 weeks (in 1981), she underwent resection of a coarctation followed by end-to-end anastomosis. When she was 2 years old, percutaneous balloon dilation was performed to treat recoarctation. At that time, percutaneous transluminal angioplasty (PTA) of a coarctation was one of the first performed worldwide.
At the age of 6 years, she had arterial hypertension again, and a patch enlargement was performed at the site of recoarctation by using xenopericardial tissue. Again she did well initially but required antihypertensive treatment with a ß-blocker and a converting-enzyme inhibitor at the age of 8 years.
When she was 19 years old, severe arterial hypertension developed during exercise (systolic blood pressure > 220 mm Hg), and she experienced headaches. Magnetic resonance (MR) angiography revealed a long stenotic segment in the proximal descending aorta (diameter, 3 to 4 mm), a tubular hypoplasia of the mid and distal aortic arch (8 mm), and a pseudoaneurysm (2.9 cm) at the site of the previous coarctation repair. At that time, she was presented to the cardiologists, who unfortunately decided to perform percutaneous balloon dilation and stenting with a 16-mm Wallstent (Boston Scientific, Natick, MA). As expected, the hypoplastic segment could not be dilated, the pressure gradient remained constant (90 mm Hg), and the pseudoaneurysm was left untreated (Fig 1). A triple antihypertensive treatment including a calcium-channel blocker was started.
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Fig 1. Computed tomography after percutaneous dilation and stenting of the descending aorta shows the still-perfused pseudoaneurysm at the site of initial coarctation.
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In 2002, at the age of 21 years, she was referred to our institution because she had asked for a definitive treatment with less antihypertensive medication. At that time, MR angiography did not show any difference when compared with that 2 years before, except that the size of the aneurysm had increased to 3.5 cm (Fig 2). The proximal end of the Wallstent was lying in the origin of the left carotid artery.
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Fig 2. Preoperative magnetic resonance angiography shows a moderate dilatation of the ascending aorta, a hypoplastic mid and distal aortic arch, and a long stenotic segment in the proximal descending aorta. The left subclavian artery originates from the pseudoaneurysm.
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The operation was performed through a median sternotomy. An arterial perfusion cannula was inserted into the left radial artery and a sheat was inserted into the femoral artery for pigtail catheter angiography. Intravascular ultrasound was used for precise intraoperative localization of the aneurysm at the level of the previous coarctation patch repair.
The ascending aorta, the aortic arch, and the supraaortic branches were dissected free. The descending aorta was exposed retropericardially by using gentle luxation similar to the techniques used in off-pump coronary artery bypass operations. After administration of 5000 IU of heparin intravenously, the descending aorta was clamped tangentially, and an end-to-side anastomosis was constructed with a ring-reinforced 16-mm expanded polytetrafluoroethylene (ImpraFlex; Impra Inc, Tempe, AZ). After local hemostasis, the posterior pericardium was readapted. The graft was positioned along the inferior aspect of the heart and the right atrium. The proximal anastomosis of the aortic bypass graft was performed to the lateral aspect of the ascending aorta. The left carotid artery was oversewn at the origin from the aorta. An 8-mm expanded polytetrafluoroethylene bypass graft was inserted between the ascending aorta and the left carotid artery to restore antegrade perfusion, and finally the left subclavian artery was transposed directly to the left carotid artery through the sternotomy approach. Intravenous heparin was repeated, and, finally, a 14-mm self-expanding flexible Wallgraft (Boston Scientific, Natick, MA) endoprosthesis was inserted within the previous Wallstent. This allowed complete exclusion of the pseudoaneurysm (Fig 3).
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Fig 3. Combined surgical and endovascular procedure, with introduction of the covered stent within the previous Wallstent to exclude the pseudoaneurysm.
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The patient recovered extremely well without any cardiac, neurologic, or bleeding complication and was discharged 1 week after the intervention. At the 6-month follow-up she was healthy and had normalized blood pressure, both at rest and during exercise under a mild dosage of ß-blocker. Postoperative MR angiogram demonstrated a patent aortic bypass graft and complete exclusion of the aneurysm due to occlusion of the covered stent (Fig 4).
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Fig 4. Preoperative (A) and postoperative (B) magnetic resonance angiography showing the complete exclusion of the pseudoaneurysm, the ascending-to-descending aortic bypass graft, a patent ascending aorta-to–left carotid bypass graft, and the transfer of the left subclavian artery to the left carotid artery.
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Comment
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The prevalence of recurrent coarctation varies widely from 7% to 60% [1, 2]. In uncomplicated cases, the standard approach is percutaneous balloon dilation and stenting [2]. However, in the presence of diffuse tubular hypoplasia of the aortic arch or in case of aneurysmatic lesions from previous interventions, this approach cannot be recommended. Most of the procedures performed directly on the narrowed segment require CPB and extensive dissection of the structures adjacent to the aorta, with a considerable risk of injury to the recurrent and phrenic nerves and perioperative bleeding. Extraanatomic ascending-to-descending aortic bypass grafting represents a valid alternative because it does not need dissection or cross-clamping of the diseased aortic segment; CPB is not necessary, and midterm results are excellent [5, 6].
Some patients with a so-called recoarctation have a hypoplasia of the aortic arch rather than re-stenosis at the original coarctation site. This might be due to inadequate initial repair or inappropriate growth of the aortic arch.
The feasibility of stent graft repair for aneurysms and dissection of the descending aorta has been documented, and some agreement exists regarding the major constraints necessary to ensure success [7, 8]. The most complex region of the thoracic aorta to be treated is certainly the aortic arch [4].
Dake and colleagues [7] first reported the clinical feasibility of endovascular repair with Dacron-covered (DuPont, Wilmington, DE) self-expanding stainless steel straight stent grafts in 13 cases of aneurysm of the descending aorta. In fact, only very few patients are presently suitable for endovascular treatment of the aortic arch because stent graft repair requires adequate proximal and distal landing zones, which are not always available [8].
We previously described the advantages of a combined surgical and endovascular approach for traumatic injury of the aortic arch and isthmus [9]. In this case, the extraanatomic aortic bypass graft combined with partial debranching of the supraaortic vessels led to normalization of the blood pressure, and the endoprosthesis allowed complete exclusion of the pseudoaneurysm. Transposition of the left subclavian artery to the left carotid artery restored antegrade flow and was performed through the same incision. CPB was not necessary during this complex procedure.
Individual tailoring of the treatment of complex aortic coarctation is essential to obtain excellent results with minimal intraoperative/intraprocedural risks. In this case, the combination of operation and endovascular treatment allowed to successfully treat a complex coarctation with several previous surgical and percutaneous interventions. No complications occurred, and blood pressure was normalized.
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References
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- Amato JJ, Douglas WI, James T, Desai U. Coarctation of the aorta. Semin Thorac Cardiovasc Surg. 2000;3:125–141
- Magee AG, Brzezinska G, Qureshi SA, et al. Stent implantation for aortic coarctation and recoarctation. Heart. 1999;82:600–606[Abstract/Free Full Text]
- Mitchell RC. Stent grafts for the thoracic aorta: a new paradigm? Ann Thorac Surg. 2002;74:S1818–1820[Abstract/Free Full Text]
- Gorich J, Asquan Y, Siefarth H. Initial experience with intentional stent-graft coverage of the subclavian artery during endovascular thoracic aortic repairs. J Endovasc Ther. 2002;9(Suppl 1):1139–1143
- Kanter KR, Erez E, Williams WH, Tam VK. Extra-anatomic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg. 2000;120:885–890[Abstract/Free Full Text]
- Connolly HM, Schaff HV, Izhar U, Dereani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation. 2001;104:1133–1137
- Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med. 1994;331:1729–1734[Medline]
- Criado FJ, Clark NS, Barnatan MF. Stent-graft repair in the aortic arch and descending thoracic aorta: a 4-year experience. J Vasc Surg. 2002;36:1121–1128[Medline]
- Carrel T, Do-dai D, Müller M, Triller J, Mahler F, Althaus U. Combined endovascular and surgical treatment of complex traumatic lesions of the thoracic aorta. Lancet. 1997;350:1146[Medline]
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Abstract
Introduction
