Ann Thorac Surg 2006;82:346
© 2006 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Surgical Treatment of Aortic Isthmic Coarctation With Aortic Aneurysmatic Looping
Simone Speggiorin, MD
a
,
Massimo A. Padalino, MD
a
,
Alberto Tregnaghi, MD
c
,
Massimo Napodano, MD
b
,
Angelo Ramondo, MD
b
,
Maurizio Giosuè Rubino, MD
a
,
Giovanni Stellin, MD
a
,
*
a Pediatric Cardiovascular Surgery Unit, University of Padova, Padova, Italy
b Department of Cardiology, University of Padova, Padova, Italy
c Institute of Radiology, University of Padova, Medical School, Padova, Italy
* Address correspondence to Dr Stellin, Pediatric Cardiovascular Surgery Unit, Centro Gallucci, Via Giustiniani, 2, Padova, 35128 Italy (Email: giovanni.stellin{at}unipd.it).
A 17-year-old African boy was referred to our division with a diagnosis of aortic coarctation associated with arterial hypertension (170/70 mm Hg). The patient had been submitted to ventricular septal defect repair at 10 months of age in a different institution, and no evidence of aortic coarctation was found at that time. On admission, he was a well developed young man, suffering from occasional fatigue with moderate effort. Physical examination showed a systolic ejective murmur on the left upper sternal border and absence of peripheral pulses in the lower limbs.
Preoperative cardiac catheterization angiography (Fig 1) demonstrated a vascular looping between the left carotid artery and an aneurysmatic left subclavian artery. His ascending aorta and other brachiocephalic vessels were normal in size and course with a pressure gradient through aortic isthmus that was 80 mm Hg. Three-dimensional magnetic resonance imaging was performed (Fig 2A). Computerized reconstruction visualized an aneurysm of the distal transverse aortic arch that was twisting medially and backward, then upward, and finally downward to the coarctation site. Figure 2 shows the aortic arch as seen from the front (Fig 2A), from the left (Fig 2B), from the back (Fig 2C), and from the right (Fig 2D) sides. In view A, the ascending aorta (AA) is continuing into a dilated distal aortic arch. This aneurysmal portion of the vascular loop (*) is seen going rightward and backward in views Figure 2A and Figure 2B. The dilatated left subclavian artery and coarctation site are clearly visualized on views in Figure 2B and Figure 2D. The aortic isthmus was measured to be 12 mm.
Surgical repair was performed uneventfully through a left posterolateral thoracotomy, on partial circulatory bypass, the left subclavian aneurysm and the aortic coarctation were resected, and the aortic reconstruction was achieved by means of an interposition tubular graft (Goretex, size 22 mm; W. L. Gore & Associates, Inc, Flagstaff, AZ).
Three-dimensional magnetic resonance imaging was performed 30 days after discharge (Fig 3). It shows a good surgical result; the aortic arch is seen from different sides as in Fig 2. The tubular prosthesis (P) is anastomosed proximally to the ascending aorta (AA) and distally to the descending aorta at the origin of the left subclavian artery.
This case illustrates the excellent diagnostic potential and accuracy of a noninvasive procedure such as 3-dimensional angiographic magnetic resonance imaging in detecting unusual vascular anomalies.
