EComment. Ascending-descending aortic bypass in patients with complex aortic coarctation

Abstract

We read Ugur et al.'s study with interest [1]. Aortic coarctation surgery may be considered a well established procedure in paediatric congenital heart surgery. However, it becomes a complex and challenging procedure in adulthood, especially in the presence of accompanying anomalies. Until the last decade, ascending-descending aortic bypass with a posterior pericardial approach via a sternotomy has been the gold standard for complex coarctation with excellent outcomes [2]. In the era of endovascular interventions, balloon dilatation and stenting have gradually become a reliable option for the management of isolated aortic coarctation [3]. Recently, a hybrid approach has become an alternative technique for treatment of complex cases with encouraging early results [4]. In our institution, we performed ascending-descending aortic bypass as a concomitant procedure in 11 adult patients (9 patients with aortic coarctation and 2 patients with type C interruption of aorta), who had accompanying cardiac diseases. All procedures were done with a median sternotomy and cardiopulmonary bypass in single stage. We performed simultaneous aortic valve replacement, coronary artery bypass grafting, ascending aorta replacement and the Bentall procedure in 4, 3, 2, and 2 patients, respectively. Ascending-descending aortic bypass was done with an anterior aortic approach. The Dacron graft was anastomosed to the lateral ascending aorta and extended toward the left ventricle lateral border. The posterior pericardium was opened and the descending aorta encircled. Descending aorta anastomosis was done with a side clamp. All patients survived surgery without any major adverse cardiac and neurologic events. One patient was reoperated because of infective endocarditis in the second postoperative month. No major adverse cardiac or cerebrovascular events were found in medical follow-up records. The hybrid approach may provide safe and simple repair of coarctation and shortens operative time in patients with accompanying cardiac diseases. Aortic rupture, aneurysmal dilatation, dissection, pseudoaneurysm, restenosis and stent fracture are infrequent but life-threatening complications. Although balloon dilatation and stenting is a well-established treatment in the paediatric population, long-term outcomes and prospective randomized studies comparing surgery and endovascular approaches are necessary in the adult population. Furthermore, extra-anatomic bypass with median sternotomy is a well known technique facilitating the single stage management of concomittant cardiac problems. Limited posterior pericardial incision usually provides adequate exposure for distal anastomosis and decreases the risk of bleeding from excessive collateral vessels. Briefly, we still consider ascending-descending aortic bypass with median sternotomy to be the preferred approach in patients with complex aortic coarctation. Conflict of interest: none declared