Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation

Reoperative approach after extra-anatomic ascending-to-descending aortic bypass graft

BACKGROUND

Extra-anatomic ascending-to-descending aortic bypass grafts have historically been utilized as a safe and effective solution for repairs of complex coarctation of the aorta. However, reports on reoperation in these patients remain rare. We present a case of an aortic valve replacement and coronary artery bypass grafting in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.

CASE PRESENTATION

The patient is a 59-year-old male with a complex aortic history, including repair of aortic coarctation with an ascending-to-descending aortic bypass graft 13 years prior, was admitted to the hospital for shortness of breath and chest pain that had developed over the past year. On further workup, he was found to have severe bileaflet aortic valve stenosis, non-ST elevation myocardial infarction, and moderate coronary artery disease. He underwent surgical aortic valve replacement and coronary artery bypass grafting. Given his unique anatomy, cardiopulmonary bypass approach involved separate cannulation of the right axillary and left common femoral arteries with cross-clamp of both the aorta and the extra-anatomic graft. Using this approach, the redo operation was successfully performed.

CONCLUSIONS

Reports on reoperation after ascending-to-descending aortic bypass grafting are rare. We describe our approach to cardiopulmonary bypass and reoperation in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.

Associated Risk Factors and Complications in Vascular Surgery Patients Requiring Unplanned Postoperative Reintubation

OBJECTIVE

To determine the frequency of reintubation within 30 days in vascular surgery patients and the associated risk factors and complications.

DESIGN

Retrospective cohort study with univariate and multivariate analyses of risk factors and outcomes from data collected by the American College of Surgeons National Surgical Quality Improvement Program.

SETTING

All institutions participating in the American College of Surgeons National Surgical Quality Improvement Program.

PARTICIPANTS

All patients older than 18 undergoing vascular surgery.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

A reintubation rate of 2.2% among vascular surgery patients within the first 30 days was demonstrated. Reintubation was associated positively with increased age, low body mass index, poor functional status, smoking status, chronic obstructive pulmonary disease, congestive heart failure, and increased anesthesia and surgical times. In addition, specific procedures were found to have significantly increased rates of reintubation, including bypass surgery, thrombectomy, and open thoracic and abdominal aorta surgery. Reintubation was associated positively with all measured complications, including a quadrupled length of average hospital stay (19.8 v 5.5 days), a 10-fold risk of mortality (33.9% v 2.6%), and a 40-fold risk of cardiac arrest (22.4% v 0.5%).

CONCLUSIONS

Patients undergoing major vascular surgery represent a high-risk population for unplanned postoperative reintubation. Preoperative evaluation should include the consideration of the positively associated risk factors found in this study. Due to the significant morbidity associated with unplanned reintubation, additional work is needed to identify risk factors amenable to optimization in the preoperative period.

[Treatment of native coarctation in adults]

Aortic coarctation is the reflection of a wider vasculopathy affecting the precoarctation arterial tree. Patients should be screened for associated heart disease and anomalies of supra-aortic arch vessels. Treatment options include surgical repair or balloon angioplasty with or without stent-graft implantation. Both treatment options can be complicated by recoarctation or aortic aneurysms and warrant lifelong surveillance. In adults, anatomic correction of coarctation has fewer effects on arterial pressure than in infants. Thus, systemic hypertension may persist in up to half of treated patients. Recoarctation or unrecognized aortic arch hypoplasia should nevertheless be eliminated.

Surgical Repair for Isolated Aortic Interruption in a Young Adult

Interrupted aortic arch (IAA), a rare congenital malformation of the aortic arch, is defined as a loss of luminal continuity between the ascending and descending portions of the aorta. It is rarely diagnosed as an isolated anomaly in adulthood. Surgical repair is feasible through a sternotomy or thoracotomy incision. In this report, we describe the surgical repair of an isolated IAA in a 29-year-old patient by performing an ascending-to-descending aortic bypass via a sternotomy with cardiopulmonary bypass.

Late outcomes of reintervention on the descending aorta after repair of aortic coarctation

BACKGROUND

After repair of aortic coarctation, patients may develop restenosis, aneurysms, and pseudoaneurysms at the site of prior repair. We assessed the outcomes of late reintervention on the descending aorta after aortic coarctation repair.

METHODS AND RESULTS

From March 1954 to July 2008, 130 patients had operations or endovascular procedures on the descending aorta after previous coarctation repair. We excluded patients who had complex left-sided cardiac lesions or interrupted aortic arch. Mean age at reintervention was 32±24 years and 28% were female. The interval between coarctation repair and reintervention was 17±13 years. Seventy-four percent of patients had hypertension. Reasons for reintervention were restenosis (n=122 [94%]), aneurysm (n=4 [3%]), and pseudoaneurysm (n=4 [3%]). Ninety-five patients (73%) underwent operative procedures including an extra-anatomic conduit (n=41), patch repair (n=32), interposition graft (n=14), end-end anastomosis (n=6), and subclavian flap (n=2). Thirty-five patients underwent endovascular treatment (balloon dilatation, n=22 or stenting, n=13). There was no early mortality. In the surgical group, 5 patients required early reoperation for bleeding and 5 patients had early vocal cord paralysis. One patient in the endovascular group had aortic rupture at the time of intervention requiring urgent operation. Survival was 97% at 10 years. At 5 years, freedom from a second repeat procedure on the descending aorta was 96% in the surgical group and 72% in the endovascular group (P<0.001). Five years after reintervention, fewer patients required treatment for hypertension (57% versus 74%, P<0.001) and a median of 1 antihypertensive medication was prescribed compared with a median of 2 medications preintervention.

CONCLUSIONS

Operative and endovascular management of recoarctation can be performed safely with good late outcomes.

Ascending aorta-to-descending aorta bypass via right thoracotomy for the re-coarctation of the aorta: an alternative surgical approach for re-coarctation

Surgical treatment of aortic coarctation is performed with low postoperative complication rates. However, some patients may require additional surgical interventions due to stenosis or re-coarctation of the aorta, and ascending-to-descending aortic bypass via right thoracotomy is a valid alternative approach in the adult population group. Risk of massive intraoperative bleeding due to adhesions at the previous left thoracotomy site and the risk of spinal cord ischemia due to aortic cross-clamping or injury to the recurrent laryngeal nerve may be avoided with right thoracotomy in such cases. In this report, we present an adult patient with re-coarctation of the aorta who was successfully treated by extra-anatomic ascending-to-descending aortic bypass via right thoracotomy without cardiopulmonary bypass.

Surgery for complex coarctation of the aorta

The application of improved surgical techniques to correct coarctation in the neonate and infant may in the longterm reduce the incidence of recoarctation in the adult. In addition, in many cases, catheter-based intervention offers an alternative to reoperation and the role of catheter-based intervention is likely to be extended with the introduction of improved technology. However, surgery is likely to be required in coarctation and recoarctation in the adult in some cases, particularly those with hypoplasia of the aortic arch, aneurysms of the ascending aorta and those with intracardiac pathology. Operation for primary coarctation in the adult can be performed through a left thoracotomy without significant postoperative morbidity. However, this is not the case with recoarctation where reoperation through a left thoracotomy has resulted in a high incidence of postoperative complications including residual coarctation, false aneurysm and recurrent laryngeal nerve palsy. Repair through a median sternotomy offers an alternative surgical approach to recoarctation which avoids these complications and allows concomitant procedures for problems associated with arteriopathy, aortic valve disease and other associated intracardiac anomalies. The approach to coarctation and recoarctation in the adult should be tailored to individual patients and made after careful discussion with interventional cardiologists.

Circulatory arrest for repair of postcoarctation site aneurysm

BACKGROUND

Aneurysm at previous coarctation repair may be seen more frequently as children operated for this condition survive into adulthood. We use deep hypothermic circulatory arrest to repair these aneurysms.

METHODS

A case series was conducted using 12-year, single-institution, retrospective chart review.

RESULTS

Twenty-one patients underwent left thoracotomy and repair of aneurysm at the site of previous coarctation repair. Three cases presented emergently as aortobronchial fistulas. The age range was 16 to 73 years (median, 26 years). The median circulatory arrest time was 33 minutes (range, 22 to 55 minutes). Repair involved interposition graft replacement. Six patients required additional tube graft replacement of the left subclavian artery. There was 1 operative mortality in a patient having a hypoxic brain injury secondary to an anaphylactic reaction to a plasma expander. There were no embolic strokes or paraplegia. One patient had a recurrent laryngeal nerve paresis. There was 1 case of Horner's syndrome after subclavian artery replacement.

CONCLUSIONS

Circulatory arrest allows for the accurate repair of this difficult pathologic process and avoids the risk of clamp-related injuries. Follow-up out to 16 years demonstrates this technique of repair to be durable, with no late deaths or reoperations for recurrent aneurysm.

Antero-axillary access for hypoplastic aortic arch repair

A 16-year-old adolescent presented with systemic hypertension due to a hypoplasia of the aortic arch resulting in a significant stenosis. In childhood, he underwent surgery for aortic coarctation through a left posterolateral thoracotomy. We present the successful repair of the complete aortic arch that could be achieved applying a patch plasty of bovine pericardium through an anteroaxillary thoracotomy.

Reoperation and coarctation of the aorta: the need for lifelong surveillance

BACKGROUND

We report a series of reoperations in 23 patients who had undergone previous aortic coarctation repair.

METHODS

The medical records of these patients were reviewed, and the patients were followed up by telephone interview. Mean age at reoperation was 25 years. There was a mean of 18 years between initial coarctation repair and reoperation. Indications for reoperation included recoarctation (9 patients), aortic aneurysm (8), aortobronchial fistulas with exsanguinating hemorrhage (2), subaortic stenosis (1), ruptured thoracic aneurysm (1), ruptured sinus of Valsalva aneurysm (1), and supramitral stenosing ring (1).

RESULTS

There were no specific intraoperative complications. Three patients required reexploration for bleeding. An acutely ischemic lower limb developed in 1 patient secondary to a common femoral artery embolus, which necessitated embolectomy.

CONCLUSIONS

Reoperation for postcoarctation repair patients can be performed with good results. Sudden life-threatening hemorrhage due to aortobronchial fistulas in patients having undergone Dacron patch aortoplasty, as well as long-term obstructive phenomena seen anywhere along the left ventricular outflow tract, make lifelong surveillance of these patients mandatory.