| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2006;81:758-760
© 2006 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
b Department of Pediatric Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Accepted for publication November 2, 2004.
* Address correspondence to Dr Pacini, c/o Unità Operativa di Cardiochirurgia, Università degli studi di Bologna, Policlinico S. Orsola, Via Massarenti 9, Bologna, 40138 Italy (Email: dpacini{at}hotmail.com).
 |
Abstract |
|---|
 Top Abstract IntroductionTechniqueCommentReferences |
|---|
|
Introduction |
|---|
|
TopAbstractIntroductionTechniqueCommentReferences |
|---|
We propose a single-stage corrective re-repair of these complex lesions through median sternotomy using antegrade selective cerebral perfusion and moderate hypothermia.
|
Technique |
|---|
|
TopAbstractIntroductionTechniqueCommentReferences |
|---|
|
|
After endotracheal intubation with a double-lumen tube, the patient was positioned on the operating table supine with the patient's left arm stretched above the head with a pillow placed under the left shoulder. A standard median sternotomy was used in all patients. Cardiopulmonary bypass was instituted with a cannula for arterial return in the femoral artery and a venous single two-stage cannula in the right atrium. Antegrade selective cerebral perfusion with moderate hypothermic circulatory arrest was utilized in all patients.
The left recurrent laryngeal nerve was identified and protected. The pseudoaneurysm and the descending thoracic aorta were exposed through the left pleural space with a downward gentle retraction of the left lung (Fig 2A). Distally the aorta was transacted circumferentially below the level of the pseudoaneurysm and a gelatin-sealed vascular graft was implanted. As this suture line was completed, the cardiopulmonary bypass was re-started antegradely, permitting the evaluation of the distal anastomosis (Fig 2B).
|
The extent of the repair and the associated procedures performed are shown in Table 1.
There were no in-hospital deaths. No patients suffered from stroke or temporary neurologic dysfunction and no one required reoperation for bleeding. One patient had pneumonia.
Cardiopulmonary bypass mean time was 196 ± 44.9 (range, 161 to 261 minutes). The mean cross-clamp time was 146.3 ± 43.1 minutes and the antegrade selective cerebral perfusion time was 114.3 ± 29.7 minutes (range, 87 to 146 minutes). The mean duration of lower body ischemia was 63 ± 45 minutes.
All patients were discharged from the hospital with antihypertension medications. Patients were followed-up for a mean duration of 10.50 ± 6.81 months. All patients underwent postoperative magnetic resonance or computed tomographic scan, which showed good results of the surgical correction.
|
Comment |
|---|
|
TopAbstractIntroductionTechniqueCommentReferences |
|---|
These lesions are typically managed with the clamping technique through a left thoracotomy with or without some form of left heart or cardiopulmonary bypass.
Recently some authors have suggested deep hypothermic circulatory arrest as an appropriate technique to approach this difficult lesion, and they have reported very excellent results [6, 7]. Deep hypothermic circulatory arrest permits an accurate repair, avoids the risk of clamp-related injuries, and provides adequate protection of the brain, spinal cord, and other organs. However, in cases of coexisting aortic arch hypoplasia, frequently associated with dilatory abnormalities of the ascending aorta and with intracardiac lesions, the lateral approach does not allow the performance of surgical maneuvers on the ascending aorta or the heart, or both.
We treated 4 patients with aneurysm or pseudoaneurysm at the site of coarctation repair and with a concomitant aortic arch hypoplasia. Successful anatomic repair was achieved in all patients through an anterior approach using antegrade selective cerebral perfusion and moderate hypothermia. There were no deaths, and none of the patients had a central neurologic deficit (stroke or spinal cord injury, or both).
We obtained the exposure of the descending thoracic aorta through the left pleural space with a gentle retraction of the left lung toward the patient's feet. In this manner we could easily reach the descending aorta down to T6-T8, allowing us to safely perform the distal anastomosis. However, in case of difficult exposure of the distal aorta, an additional left anterior thoracotomy could be made.
Exposure of the subclavian artery, especially if associated with a large aneurysm, can be technically challenging. In 1 patient, we decided to close the subclavian artery because the reimplantation was technically too demanding. This patient experienced neither symptoms nor functional deficits at the follow-up.
The risk of spinal cord ischemic injury is substantial when no distal perfusion techniques are used. In such cases, spinal cord protection can be achieved only with hypothermia, and for ischemic times shorter than 60 to 90 minutes, moderate hypothermia at 26°C nasopharyngeal appears to be adequate [8]. Our mean lower body ischemic time was 63 minutes, and no patient had evidence of neurologic deficits such as paraplegia or paraparesis.
In conclusion, this procedure should be considered as a suitable alternative for adult patients with aortic coarctation or with pseudoaneurysm at the site of the previous repair and a concomitant hypoplastic aortic arch. Excellent surgical results can be obtained in this technically challenging group of patients.
|
References |
|---|
|
TopAbstractIntroductionTechniqueCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  L. Botta, V. Russo, G. Oppido, M. Rosati, F. Massi, L. Lovato, R. Di Bartolomeo, and R. Fattori Role of endovascular repair in the management of late pseudo-aneurysms following open surgery for aortic coarctation Eur. J. Cardiothorac. Surg., October 1, 2009; 36(4): 670 - 674. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
