Complex Aortic Coarctation Research Articles

Late Outcomes of Ascending-to-Descending Bypass for Aortic Coarctation

Ascending-to-descending aortic bypass is a repair option for patients with complex aortic coarctation. This technique is reported to have minimal early morbidity and mortality, however, the long-term results of the procedure are unknown. We analyzed the late outcomes of 81 consecutive patients with aortic coarctation who underwent ascending-to-descending aortic bypass through a median sternotomy from January 1985 to December 2012. The study was limited to this interval to allow for a minimum of 10-year follow-up. Fifty-two patients had recurrent coarctation after previous repair, and 44 patients had concomitant cardiac procedures at the time of ascending-to-descending bypass. There was no perioperative mortality, and overall survival at 5, 10, and 20 years was 94%, 90%, and 85%, similar to an age and sex-matched population. There were no interventions for the ascending-to-descending bypass during follow-up, and no deaths were known to be related to the bypass graft. Subsequent cardiac operations were performed through a median sternotomy in 7 patients (9%), and late imaging in 48 patients (59%) demonstrated no hemodynamically significant stenoses or pseudoaneurysms. At late follow-up, median systolic blood pressure was 124 mmHg, and half of the patients were on no or only one antihypertensive. Ascending-to-descending aortic bypass is a safe operation with excellent long-term outcomes for adult patients with complex aortic coarctation. The procedure is durable and appears to improve systemic hypertension. Importantly, ascending-to-descending bypass does not hinder the safe performance of subsequent operations performed through a median sternotomy.

Late pseudo-aneurysms after coarctation repair with extra-anatomic ascending-descending aortic bypass surgery

Abstract Background Extra-anatomic ascending-descending aortic bypass operations are an alternative to difficult aortic arch reconstruction in patients with complex aortic coarctation. Reported short-term results are favorable, however, data on long-term outcomes are sparse. The aim of our study was to report long-term outcomes in affected adult patients. Methods We identified all adults with extra-anatomic ascending-descending aortic bypass surgeries followed at our center. Outcomes were assessed by chart review with a specific focus on formation of late pseudo-aneurysms and requirement for redo surgery. Results We identified a total of 12 adults (67% males) with previous ascending-descending aortic bypass surgery. These patients account for 12/171 (7%) of adults with aortic coarctation followed at our center. 10/12 patients (83%) had undergone coarctation repair by different repair techniques before ascending-descending aortic bypass surgeries. Median age at ascending-descending aortic bypass surgery was 17 years (range: 7-42 years). Prosthetic conduit sizes ranged from 12-22mm. In long-term follow-up, 11/12 patients (92%) required antihypertensive medication (median 2 antihypertensive drugs, 50% ≥ 3 drugs). A total of 5/12 patients (42%) required redo-surgery for formation of pseudo-aneurysms (figure 1) at graft anastomoses (4 proximal anastomosis at ascending aorta, 1 distal anastomosis to descending aorta) at a median age of 47.6 years (28.2-65.0 years) and a median of 22.1 years (range: 14.7-24.6 years) after the initial extra-anatomic ascending-descending aortic bypass operation (figure 2). Two of these patients required redo-operations / interventions for recurrent pseudo-aneurysms at 26 and 33 months after the redo-operations. Conclusions Although reported short- and medium-term outcomes after ascending-descending aortic bypass surgery for complex aortic coarctation are favorable, our data suggest a high rate of pseudo-aneurysm formation late (>10 years) after surgery. Our data highlight the need for careful long-term (life-long!) follow-up of these patients at specialized centers.

Adult complex aortic coarctation

Adult complex aortic coarctation

Revascularization of Left Subclavian to Common Carotid Artery Prepares for Covered Stent Implantation in Patients With Complex Aortic Coarctation.

Seven adult patients underwent a two-stage treatment of complex coarctation (CoA), including surgical revascularization of the left subclavian artery (LSA) to left common carotid artery (LCCA), followed by transcatheter covered stent implantation. The majority of patients (5 of 7, 71%) received 1 covered stent (covered Cheatham Platinum stent: 8 zig/45 mm [n = 2], 10 zig/60 mm [n = 1], 10 zig/65 mm [n = 1]; BeGraft: 24/48 mm [n = 2]). In 1 patient (14%), the implantation of 2 covered stents (BeGraft 20/48 mm) was necessary. During a median follow-up of 2.4 years (interquartile range, 0.1 to 4.9 years), complications occurred in 3 of 7 patients (43%), including an asymptomatic but severe stenosis of the LSA bypass (n = 1), a recoarctation with a mild endoleak (n = 1), and a severe endoleak (n = 1). Surgical revascularization of the LSA to the LCCA can successfully prepare for covered stent implantation in complex CoA in adult patients. This two-stage approach was feasible and safe with complications occurring in 3 of 7 patients (43%). All complications were managed by catheter reintervention only.

Simultaneously surgical management of adult complex coarctation of aorta concomitant with intracardiac abnormality.

To explore surgical management of complex coarctation of aorta (COA) concomitant with intracardiac abnormality, in order to provide recommendations for safe and reliable treatment. Totally, six adult cases demonstrating complex COA concomitant with intracardiac abnormality were reviewed from our department between May 2012 and June 2017. Four patients were male and two patients were female, the age range being 43.8±10.6 years old. The associated intracardiac abnormality included 3 aortic root aneurysms, 3 aortic insufficiency, 1 aortic stenosis, 3 mitral regurgitation (MR), 1 coronary artery disease (CAD), 1 patent ductus arteriosus (PDA) and 1 ventricular septal defect (VSD). All patients received extra-anatomic aortic bypass approach to tackle complex COA. The extra-anatomic aortic bypasses comprised 4 ascending-descending aortic bypass grafting and 2 ascending-abdominal aortic bypass grafting. Simultaneous intracardiac abnormality repair procedures comprised 3 Bentall procedures, 1 aortic valve replacement, 3 mitral valve repairs, 1 coronary artery bypass grafting, 1 PDA repair and 1 VSD repair. There was no early or late mortality. None of the patients suffered from stroke or paraplegia. Only 1 patient received reexploration for hemostasis because of post-pericardial anastomosis bleeding. The same patient suffered from acute renal failure, but completely recovered after 7-day hemodialysis. All other patients had uneventful post-operative recoveries. The follow-up (mean 37±22.9 months) showed that all patients survived and all patients' blood pressures significantly decreased (pre-operative 165.8±16.3mmHg versus post-operative 121.5±10.8 mmHg, P<0.05). All patients have significantly reduced ankle-brachial pressure gradients (pre-operative 63.3±17.2 mmHg versus post-operative 29.1±4.3 mmHg, P<0.05). All aortic grafts maintained patent flow. Simultaneous management of complex COA concomitant with intracardiac abnormality is a safe and reliable surgical method.

A Special Type of Complex Coarctation of Aorta with Total Lumen Occlusion Treated by Radiofrequency

Coarctation of aorta (CoA) accounts for between 7% and 10% of cases of congenital heart disease1. Aortic atresia (complete aortic occlusion) is a special and very uncommon type characterized by the total abscence of distal flow, but with luminal continuity between the ascending and descending aorta. Normally occurs in cases of untreated long – standing CoA which progress to complete occlusion Diagnosis is usually established in the context of the study of HTA, stroke or heart failure. It´s usually accompained by extensive collateral circulation and degeneration of aortic wall which can trigger complication such as aneurysm and dissections or even aortic rupture. Surgical treatment is associated with a high rate of morbidity and mortality and for this reason percutaneous treatment has become relevant in recent years. It is performed by dual arterial access, due to the lenght of the occlussion , it couldn´t be crossed by angioplasty guidewire and we used a radiofrecuency catheter so as to cross. Once the occlusion was crossed we stablished a radial-femoral loop and then we proceeded to a progressive dilatation and finally a covered stent implantation. The collateral circulation is usually highly developed, which confers special surgical difficulty and risk on the procedure. This has led to the development of the percutaneous approach, with techniques for crossing the occluded segment using coronary angioplasty or radiofrequency guidewires (in cases of long occluded segments) and implantation of a stent, which should preferably be covered with ePTFE, The ePTFE stents could be recommended in this type of complex intervention in calcified aortas with a loss of structure due to medial cystic necrosis, which can progress to the formation of aneurysms, dissections, or even rupture. The stent should be positioned correctly in the wall with its ePTFE covering in order to reduce the incidence of complications

A Special Type of Complex Coarctation of Aorta with Total Lumen Occlusion Treated by Radiofrequency

A Special Type of Complex Coarctation of Aorta with Total Lumen Occlusion Treated by Radiofrequency

P1633Intrapericardial ascending to descending aortic graft: a simple, safe and definitive alternative intervention for adults with complex aortic coarctation

P1633Intrapericardial ascending to descending aortic graft: a simple, safe and definitive alternative intervention for adults with complex aortic coarctation

Stenting complex aortic coarctation: simulation in a 3D printed model.

Stenting complex aortic coarctation: simulation in a 3D printed model.

Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch.

Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch. Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9-23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmHg at rest and 180 ± 40 mmHg during exercise, with a mean pressure gradient of 80 ± 11.6 (range 40-120) mmHg. Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10-26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmHg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon. Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.

Stenting of complex coarctation of aorta with aberrant right subclavian artery

Coarctation of aorta with aberrant right subclavian artery distal to coarctation is very rare. Detailed evaluation and planning is required for management of such case. Coarctation of the thoracic aorta (CoA) occurs at an incidence of approximately 1:1000 in the general population, ranging from 0.08 to 0.14% in large surveys. Anomalous origin of right subclavian artery (RSCA) is reported in up to 1% cases of CoA.Presence of aberrant RSCA makes treatment of such anomaly challenging. We report here successful placement of bare metal stent in a young lady with severe CoA and aberrant RSCA distal to CoA. Transcatheter stenting of CoA with aberrant RSCA is safe and effective procedure with good outcome. A detailed preprocedure evaluation and planning is the key to success.

Augmentation of the Lesser Curvature With an Autologous Vascular Patch in Complex Aortic Coarctation and Interruption

Reconstruction of the aortic arch in patients with complex aortic coarctation or interruption continues to be a challenge because of early left mainbronchial compression or recoarctation and late Gothic arch formation. We propose a modified arch reconstruction technique augmenting the lesser curvature with an autologous vascular patch, which can relieve tension on the anastomosis without a prosthetic material. We retrospectively reviewed 33 patients with coarctation and arch hypoplasia (n= 31) or arch interruption (n= 2) who underwent arch reconstruction with an autologous vascular patch from 2007 to 2012. Median age at the operation was 17 days (range, 5 to 200 days). Median body weight was 3.7 kg (range, 2.3 to 7.0 kg). Cardiopulmonary bypass was used for all operations. Median antegrade selective cerebral perfusion time was 35 minutes (range, 23 to 59 minutes). Combined intracardiac anomalies in 29 patients (88%) were corrected simultaneously. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from aortic isthmus (n= 25), pulmonary artery (n= 4), left subclavian artery (n=2), aberrant right subclavian artery (n= 1), or distal arch (n= 1). One patient (3%) died of acute respiratory distress syndrome. All survivors were discharged at 15days (range, 7 to 58 days) postoperatively without neurologic complications or bronchial obstructions. Median follow-up was 24.8 months (range, 0.2 to 48.5 months). No recoarctation was observed during follow-up, and no patient needed reoperation. Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in excellent midterm outcomes. Not only can a more natural shape of arch and less tension on the anastomosis be obtained, but complications, such as left main bronchial obstruction or recoarctation, can also be minimized. Long-term follow-up is needed to evaluate late development of recoarctation, hypertension, or aneurysm formation.

Thoracic Stent Graft Implantation for Aortic Coarctation with Patent Ductus Arteriosus via Retroperitoneal Iliac Approach in the Presence of Small Sized Femoral Artery.

Endovascular stent graft implantation is a favorable method for complex aortic coarctation accompanied by patent ductus arteriosus. Herein, an 18-year-old woman with complex aortic coarctation and patent ductus arteriosus was successfully treated by endovascular thoracic stent graft via retroperitoneal approach. The reason for retroperitoneal iliac approach was small sized common femoral arteries which were not suitable for stent graft passage. This case is the first aortic coarctation plus patent ductus arteriosus case described in the literature which is treated by endovascular thoracic stent graft via retroperitoneal approach.

Surgical Treatment for Complex Coarctation of Aorta

Surgical Treatment for Complex Coarctation of Aorta

Ascending-to-Descending Aortic Bypass: A Simple Solution to a Complex Problem

Surgical correction of complex aortic coarctation can be associated with significant risks. Extraanatomic bypass may represent a safer alternative. Between January 1985 and December 2012, 80 consecutive patients with complex coarctation underwent ascending-to-descending aortic bypass through a median sternotomy. Patients were a median age of 42 years (range, 15 to 75 years), and 51 (64%) were males. Recurrent coarctation was present in 52 patients (65%), with 6 (8%) having undergone balloon dilatation. Uncontrolled hypertension was present in 63 patients (79%). The most common concomitant pathology was aortic valve stenosis in 21 patients (26%), subaortic stenosis in 10 (13%), and Shone complex in 4 (5%). There were no early deaths. The most common concomitant procedures were aortic valve replacement, coronary artery bypass grafting, and resection of subaortic stenosis. The mean aortic cross-clamp and cardiopulmonary bypass times were 33 ± 40 and 106 ± 54 minutes, respectively. Morbidity included atrial fibrillation in 17 patients (21%) and reexploration for bleeding in 6 (8%). There was no paraplegia or stroke. Upper extremity blood pressure significantly improved (p < 0.001). Mean systolic blood pressure decreased from 153 ± 26 mm Hg preoperatively to 123 ± 15 mm Hg postoperatively. Mean follow-up was 7 ± 6 years (maximum, 22 years). Late deaths occurred in 5 patients (6%) and were not graft-related. Three patients (4%) required reoperation for repair of periprosthetic regurgitation in 2 and mitral valve replacement in1. The ascending-to-descending aortic bypass can be performed with low morbidity and mortality. It is an effective solution to complex aortic coarctation and represents a safe single-stage approach for patients with concomitant cardiac pathology.

Selection Strategy and Technical Variations of Extra-Anatomic Bypass in Surgical Management of Complex and Recurrent Aortic Coarctation and Hypoplastic Arch

Selection Strategy and Technical Variations of Extra-Anatomic Bypass in Surgical Management of Complex and Recurrent Aortic Coarctation and Hypoplastic Arch

Selection strategy and technical variations of extraanatomic bypass in surgical management of complex and recurrent aortic coarctation and hypoplastic aortic arch

Method In 1989-2012, 60 patients (mean age 29 ± 6.7years) with complex aortic coarctation (n = 33), recurrent coarctation (n = 27; anastomosis pseudoaneurysm in 10), underwent correction using extraanatomic bypass, either or without extracorporeal circulation. The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, length of hypoplasia and history of previous repair. Various extraanatomic bypass strategies included left subclavian artery (LSCA) to descending aorta (DA) (n = 38), right subclavian artery (RSCA) to left carotid artery (LCA) (n = 2), LCA to LSCA (n = 3), LCA to DA (n = 2), ascending aorta (AA) to LSCA (n = 3), AA to DA (n = 4), aortic arch to DA (n = 3) and AA to abdominal aorta (n = 5). We choose the size of the graft according to the diameter of the ascending aorta.. Preoperatively, mean systolic blood pressure was 130 ±30mm Hg at rest and 180±40 mmHg during exercise, with mean pressure gradient of 80±11.6 (range 40-120) mmHg.

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

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

966Using Carotid-subclavian artery Index and Isthmus-descending Aorta ratio with cardiac MR for detection of coarctation

Objective: Coarctation of the aorta is one of the most common congenital heart diseases. Its diagnosis may be difficult in the presence of complex cardiac defects, congenital disease or of a poor echocardiographic window. In the preset study we demonstrate the carotid-subclavian artery index (CSA index) and the isthmus—descending aorta ratio (I/D ratio), two recently described indexes, are effective in detection of isolated and complex aortic coarctation in patients using cardiac MR. Many study using these index by echocardiography but there is a few study concerning using MR for detection of coarctation. Method: This is a retrospective cohort study in a tertiary care cardiac hospital. Review of all MR (0-40 aged) with a diagnosis of coarctation seen at our institution between 2010 and 2011. An age- and sex-matched control group without coarctation was constituted. Offline MR measurements of the aortic arch were performed in order to calculate the CSA index and I/D ratio. The CSA index is the ratio of the distal aortic arch diameter to the distance between the left carotid artery and the left subclavian artery. It is highly suggestive of a coarctation when it is <1.5. The I/D ratio defined as the diameter of the isthmus to the diameter of the descending aorta, suggests an aortic coarctation when it is less than 0.64. Results: Sixty-five patients included in coarctation group, 84 in control group. Patients I n coarctation groups had a significantly lower CSA index than patients in the control group (1.27 + 0.06 vs. 2.82 + 0.9, p < 0.05). I/ D ratio (0.4 + 0.14) were significantly lower than the cut- off in comparison to the previous study (0.64). Associated cardiac defects, age and sex did not alter on the CSI index or I/ D ratio. Cut-off pint of 1.5 was considered 96% as sensitivity and 76% specificity in detection of coarctation of aorta. The positive and negative predictive value was 84.4% and 94.1% respectively. Conclusion: The association of both indexes improves sensitivity and permits diagnosis of coarctation in all patients based solely on a cardiac MR measurement. We have demonstrated that CSI and I/ D ratio index, are independently of clinical status, associated anomalies age and sex, and are useful tools for detecting of aortic coarctation with cardiac MR. Keywords: Aortic Coarctation; CSI index, I/ D index, cardiac MR, congenital heart defect

Results of using cardiopulmonary bypass for spinal cord protection during surgical repair of complex aortic coarctation

The aim of this study was to evaluate the surgical treatment of complex aortic coarctation using partial cardiopulmonary bypass to increase the spinal cord protection. A total of 15 patients (age range from 7 to 48 years) underwent coarctation repair through a left posterolateral thoracotomy with cardiopulmonary bypass. Cannulation was performed via the descending aorta and the main pulmonary artery. In all, six surgeries were performed under hypothermic circulatory arrest and nine repairs were performed under mild hypothermia. The clinical outcome regarding the development of restenosis, as well as major neurologic complication, was studied. There was no mortality. None of the patients developed paraplegia. Of the 15 patients, two developed a recurrent stenosis at the proximal anastomosis between the aortic arch and the aortic prothesis at a mean follow-up of 5.5 years. In the remaining 13 patients, echocardiography and magnetic resonance imaging showed no evidence of a significant gradient. Complex aortic coarctation without hypoplasia of the proximal aortic arch and intra-cardiac anomalies can be repaired with low mortality and neurologic morbidity via a left thoracotomy using cardiopulmonary bypass. The use of cardiopulmonary bypass goes along with a low risk of spinal cord and lower body ischaemia and provides a sufficient amount of time for the anastomoses.