Ann Thorac Surg 2011;92:1106-1108. doi:10.1016/j.athoracsur.2011.03.050
© 2011 The Society of Thoracic Surgeons
Case Reports
Open Plugging and Extra-Anatomical Bypass for Iatrogenic Rupture of Coarctation of the Aorta
Takashi Ogasawara, MD,
Kazuyuki Daitoku, MD,
Satoshi Taniguchi, MD,
Yasuyuki Suzuki, MD,
Ikuo Fukuda, MD*
Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
Accepted for publication March 8, 2011.
* Address correspondence to Dr Fukuda, Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine 5 Zaifucho, Hirosaki, Aomori 036-8562, Japan (Email: ikuofuku{at}cc.hirosaki-u.ac.jp).
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Abstract
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We report a successful repair of aortic rupture after balloon angioplasty for re-coarctation using a unique approach and method. A 22-year-old woman underwent emergency surgery for aortic rupture after balloon angioplasty for postoperative aortic re-coarctation. We performed extra-anatomic bypass from the ascending aorta to the descending thoracic aorta through a median sternotomy and incision in the posterior pericardium. The transverse aortic arch was transected, and the distal aortic arch was opened under deep hypothermic circulatory arrest of the lower extremities. The proximal aorta was closed. To seal the aortic rupture site, a tube graft was inserted through the aortotomy and was oversewn with the aorta. Repair of the right ventricular outflow stenosis was concomitantly performed. The patient's postoperative course was uneventful, and she successfully gave birth 2 years postoperatively.
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Introduction
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Endovascular treatment for re-coarctation after subclavian flap or aortoplasty for coarctation is a less invasive procedure than open repair. However, iatrogenic aortic rupture is a potentially fatal complication and prompt management is necessary. A direct approach through re-thoracotomy is frequently difficult. We report a unique approach for aortic rupture after balloon angioplasty through a median sternotomy with aortic arch division, endo-aortic plugging and extra-anatomic aortic bypass.
A 22-year-old woman was referred to our department for management of failed balloon angioplasty for re-coarctation of the aorta. She had undergone multiple interventions for coarctation of the aorta (CoAo) with subclavian flap at 2 years old, and balloon angioplasty for re-stenosis at 5, 9, and 14 years of age. She also had a large ventricular septal defect and had undergone pulmonary artery banding through a left thoracotomy concomitantly with the subclavian flap operation at 2 years old. As natural closure of the ventricular septal defect was obtained, she underwent pulmonary artery de-banding through a median sternotomy at 5 years old.
When she became pregnant at 22 years old, echocardiography revealed re-coarctation. Cardiac catheterization demonstrated a pressure gradient of 46 mm Hg between the ascending and descending thoracic aorta. Right ventriculography revealed right ventricle outflow stenosis with a pressure gradient of 48 mm Hg. She underwent the fourth balloon angioplasty after termination of the pregnancy. During balloon angioplasty, she complained of chest pain and dyspnea. An aortogram and computed tomographic scan revealed the remaining stenosis with leakage of contrast material around the coarctation site (Fig 1
). As she was complaining of continuous back pain, surgical repair was conducted through a left thoracotomy. However, adhesion between the pleural cavity and lung was so thick that we had to abandon the re-thoracotomy approach. We adopted an alternative approach using a median sternotomy and a single-stage repair of the ruptured re-coarctation and right ventricular outflow tract stenosis. Preoperatively, the major intercostal arteries in the proximal thoracic aorta were embolized. After a median sternotomy, an 18-mm Dacron graft (Hemashield [Maquet, Rastatt, Germany]) anastomosed with a 10-mm branch to the ascending aorta during partial occlusion clamping. Cardiopulmonary bypass was established after arterial perfusion through the graft, plus the femoral artery and bicaval drainage. Her body temperature was cooled to 20°C. During cooling, the right ventricle outflow stenosis was repaired using a monocuspid patch. The apex of the heart was then elevated using a heart positioner (Acrobat Xpose [Maquet, Rastatt, Germany]) to expose the descending aorta through a longitudinal incision of the dorsal pericardial sac. A satisfactory operative field was obtained by caudal retraction of the diaphragm. A partial occlusion clamp was placed on the descending aorta and an 18-mm Dacron graft (Maquet) was anastomosed in an end-to-side fashion (Fig 2A). After deep hypothermic circulatory arrest of the lower body, the aortic arch was transected and sutured just distal to the left common carotid artery. Dissection of the aortic arch was easy, but the rupture site itself was firmly adhered to the surrounding tissue by fibrous tissue. Under cerebral perfusion through the graft, the distal aortic arch was opened. A pigtail catheter was advanced from the femoral artery to the operative field through the opened aortic stump. A 14-mm Dacron graft 8 cm in length was inserted into the descending aorta along the pigtail catheter (Fig 2B). The proximal stump of the descending thoracic aorta was then oversewn in a linear manner with the graft to cover the ruptured site (Fig 2C) Postoperatively, the patient's arterial blood pressure was 106/43 mm Hg in the right arm and 96/48 mm Hg in the right leg. An echocardiogram revealed good left ventricular function and no stenosis of the right ventricle outflow tract. A computed tomographic scan showed that the rupture site was sealed with the graft (Fig 3
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Fig 1. Preoperative computed tomographic scan of the patient. Dotted arrows indicate hematoma in the mediastinum. Solid arrows indicate pseudoaneurysm caused by rupture of the aneurysm.
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Fig 2. (A) The bypass from the ascending aorta to the descending aorta was created during cooling. A side branch was used as an aortic perfusion site. (B) A small-sized graft was inserted from the stump of the aortic arch. (C) The aortic arch was closed using the graft. The rupture site was covered internally by the graft.
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Fig 3. Postoperative three-dimensional computed tomographic scan. Orientation of the three-dimensional reconstruction is shown in the small box.
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As of 2 years postoperatively, the patient was doing well and had given birth without any complications.
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Comment
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Endovascular treatment for CoAo is an effective treatment and less invasive than an open procedure. Current angioplasty and stent placement techniques have reduced the rate of aneurysm formation and have became applicable to various types of CoAo. However, aortic rupture after endovascular treatment for CoAo represents a potentially lethal complication [1]. Chessa and colleagues [2] reported that 1 of 71 patients who underwent endovascular treatment for CoAo or re-coarctation died after repair due to iatrogenic rupture of coarctation site. Brown and colleagues [3] reported that 1 of 31 patients who underwent endovascular treatment for re-coarctation experienced aortic rupture requiring an urgent operation. Stent-graft deployment for aortic rupture after stenting for re-coarctation is an effective treatment [4]. However, insufficient dilation of the re-coarctation makes it difficult to fit the stent-graft within the hourglass-shaped aorta. Zipfel and colleagues reported that single-piece, reversed, tapered stent–grafts adapt to the special anatomy of the CoAo [5]. The most dangerous complication with a small-size stent–graft placement into the stenotic aortic isthmus is the occlusion of the stent-graft due to kinking.
Surgical management of re-CoAo remains controversial. Dibardino and colleaguesrecommended anatomical repair [6], whereas Praschker and colleagues [7] recommended extra-anatomical repair. Direct approach to the re-coarctation site may be possible, if the adhesion is loose. However, if diffuse fibrous adhesion is present, proximal control is difficult, and dissection per se may be accompanied by injury of the lung parenchyma during extensive manipulation. Aortic repair is technically demanding because of the thin and fragile aorta. Use of an extra-anatomical route avoids these problems. In addition, a median sternotomy allows the repair of other cardiac problems, as performed in our case. Exposure of the descending thoracic aorta thorough the pericardium is easy with elevation of the apex and retraction of the diaphragm [8]. Graft length is short with this intrapericardial route. In our unique approach, the coarctation site was reinforced internally by the graft, and the rupture site was plugged because reversed flow from the descending aorta compressed the graft against the aortic wall. Preparatory embolization of the major intercostal arteries also proved effective.
In conclusion, open plugging and extra-anatomical bypass for aortic rupture after angioplasty of re-coarctation is an effective and safe procedure.
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References
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- Forbes TJ, Garekar S, Amin Z, et al. Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: a multi-institutional study Catheter Cardiovasc Interv 2007;70:276-285.[Medline]
- Chessa M, Carrozza M, Butera G, et al. Results and mid–long-term follow-up of stent implantation for native and recurrent coarctation of the aorta Eur Heart J 2005;26:2728-2732.[Abstract/Free Full Text]
- Brown ML, Burkhart HM, Connolly HM, Dearani JA, Hagler DJ, Schaff HV. Late outcomes of reintervention on the descending aorta after repair of aortic coarctation Circulation 2010;122:S81-S84.[Abstract/Free Full Text]
- Alcibar J, Peña N, Inguanzo R, et al. Stent-graft deployment for aortic rupture after stenting for aortic recoarctation Tex Heart Inst J 2007;34:453-456.[Medline]
- Zipfel B, Ewert P, Buz S, et al. Endovascular stent-graft repair of late pseudoaneurysms after surgery for aortic coarctation Ann Thorac Surg 2011;91:85-91.[Abstract/Free Full Text]
- Dibardino DJ, Heinle JS, Kung GC, et al. Anatomic reconstruction for recurrent aortic obstruction in infants and children Ann Thorac Surg 2004;78:926-932.[Abstract/Free Full Text]
- Praschker BGL, Mordant P, Barreda E, Gandjbakch I, Pavie A. Long-term results of ascending aorta-abdominal aorta extra-anatomic bypass for recoarctation in adults with 27-year follow-up Eur J Cardiothorac Surg 2008;34:805-809.[Abstract/Free Full Text]
- Mckellar SH, Schaff HV, Dearani JA, et al. Intermediate-term results of ascending–descending posterior pericardial bypass of complex aortic coarctation J Thorac Cardiovasc Surg 2007;133:1504-1509.[Abstract/Free Full Text]
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Abstract
Introduction
