Patch Aortoplasty Research Articles

Postoperative Aortic Isthmus Size After Arch Reconstruction with Patch Augmentation Predicts Arch Reintervention

Reintervention rates after patch-augmented reconstruction for hypoplastic aortic arch remain moderately high. We analyzed mid-term outcomes of aortic arch reconstruction to define modifiable reintervention risk factors. Excluding Damus-Kaye-Stansel anastomoses and previous arch repair, 338 patients underwent arch reconstruction from 2000-2021 at median age 6d (IQR 4-13d) and weight 3.2kg (IQR 2.8-3.7kg). Surgical technique was patch augmentation with coarctectomy ± interdigitation in 269 (80%), isolated patch aortoplasty in 41 (12%), and other reconstruction in 28 (8%). Risk factors for reintervention were assessed using competing risk models. At median follow-up of 3.9y (IQR 1.1-8.0y), 35 (10.4%) patients required reintervention (30 endovascular, 12 surgical, 7 both). Ten-year cumulative incidence of death/transplant and reintervention were 10% (95%CI 4-20%) and 13% (95%CI 8-20%). On univariate analysis, isolated patch aortoplasty (p=0.002), aortic homograft patch material (p=0.006), and postoperative aortic size z-score ≤-2 for each segment were associated with greater risk of reintervention: ascending aorta (p=0.006), proximal (p=0.001) and distal (p=0.005) transverse arch, and aortic isthmus (p<0.001). On multivariable analysis, aortic homograft (HR 6.29, 95%CI 1.94-20.5, p=0.002) and postoperative isthmus z-score ≤-2 (HR 10.5, 95%CI 5.15-21.5, p<0.001) remained significant. Patients with repaired isthmus z-score ≤-2 had 72.8% (95%CI 44.6-94.4%) cumulative incidence of reintervention at 10 years, versus 6.8% (95%CI 4.1-11.4%) in those with z-score >-2. Aortic undersizing during patch-augmented reconstruction of hypoplastic aortic arch results in over 10% rate of reintervention at mid-term follow-up. Achieving adequate postoperative arch size is critical for preventing reintervention, with aortic isthmus size being of utmost importance.

The role of 3D technology in the practical education of congenital coarctation and its treatment—a feasibility pilot study

BackgroundCoarctation of the aorta (CoA) is a congenital disease with an incidence of 4 out of 10,000 live births, therefore proper education of its treatment is essential. Understanding the disease and the wide array of treatment options is often difficult. Additive manufacturing technology can be used to produce 3D printed hands-on surgical training tools (HOSTT), which can be used for the education and practical training of CoA. This study aimed to investigate the effectiveness of a 3D printable HOSTT for the simulation of coarctation surgery, and it’ possible role in practical education.MethodsParticipants were medical students of Semmelweis University between the second and sixth academic year. A virtual 3D model of an aorta with CoA was generated from a computed tomography angiography scan. Each participant received a 3D-printed aorta phantom and performed either one of four surgical treatment modalities. The simulated surgeries included end-to-end anastomosis, end-to-side anastomosis, prosthetic patch, and subclavian flap aortoplasty. Participants provided feedback, evaluating their understanding of the disease and its treatment by the four surgical reconstruction modalities on a seven-point Likert scale before and after the sessions.Results21 medical students participated in this study. Participants’ average rating of their understanding of CoA disease and it treatment options before practical training was 4.62 ± 1.07. After training, their average rating increased to 6.19 ± 1.08, showing statistically significant difference.ConclusionsWithin this study’s limitations, the applied HOSTT, manufactured using 3D printing, was effective for the practical training of CoA’s surgical treatment methods for medical students.

Long-Term Outcomes of Ascending Sliding Arch Aortoplasty.

Background: Coarctation of the aorta can be associated with significant hypoplasia of the aortic arch. In contrast to patch aortoplasty, ascending sliding arch aortoplasty uses viable autologous tissue for potential growth in children. We reviewed the mid- to long-term outcomes of this technique. Methods: Between 2002 and 2023, 28 patients underwent ascending sliding arch aortoplasty for the patients with coarctation of the aorta (n = 22) and interrupted aortic arch (n = 2). Four patients underwent previous surgical coarctation repair at other institutions. The median patient age and body weight were 28.5 months (3 weeks to 15.6 years) and 13.4 kg (3.7-70 kg), respectively. Results: Although one patient had a recurrent nerve injury postoperatively, there were no other major morbidities or mortalities. The last follow-up echocardiography demonstrated that the mean peak velocity improved from 3.9 ± 0.6 to 0.9 ± 0.8 m/s, and the pressure gradient improved from 63.6 ± 21.5 to 7.1 ± 7.7 mm Hg. The postoperative diameters of the ascending aorta, proximal arch, distal arch, and isthmus all increased significantly. The mean postoperative length of stay was 5.9 ± 2.1 days, and the median follow-up time was 7.3 years (10 days to 20.5 years). No reoperation or catheterization-based intervention was performed for residual coarctation. Conclusions: Ascending sliding arch aortoplasty is safe and effective for treating coarctation of the aorta with aortic arch hypoplasia. This technique is applicable for children ranging in size from neonates to older children (or adolescents), recurrent coarctation cases, and provides complete relief of narrowing by utilizing viable native aortic tissue.

From Crafoord’s End-to-End Anastomosis Approach to Percutaneous Interventions: Coarctation of the Aorta Management Strategies and Reinterventions

First described in 1760 by the anatomist Morgagni, coarctation of the aorta (CoA) is a congenital heart defect characterized by narrowing the aorta, typically distal to the left subclavian artery. It accounts for approximately 5–8% of all congenital heart diseases, with an incidence estimated at 4 per 10,000 live births. In 1944, the Swedish surgeon Clarence Crafoord achieved the first successful surgical CoA repair by performing an aortic end-to-end anastomosis on two patients aged 12 and 27 years old. Presently, the most prevalent techniques for surgical repair, particularly in infants and neonates with isolated coarctation, involve resection with end-to-end anastomosis (EEA) and the modified Crafoord technique (extended resection with end-to-end anastomosis (EEEA)). Subclavian flap aortoplasty (SCAP) is an alternative surgical option for CoA repair in patients under two years of age. In cases where the stenosis extends beyond resection and end-to-end anastomosis feasibility, patch aortoplasty (PP) employing a prosthetic patch can augment the stenotic region, especially for older patients. Despite advances in pediatric cardiology and cardiac surgery, recoarctation remains a significant concern after surgical or interventional repair. This comprehensive review aims to provide a thorough analysis of coarctation management, covering the pioneering techniques introduced by Crafoord using end-to-end anastomosis and now extending to the contemporary era marked by percutaneous interventions as well as the recoarctation rate associated with each type.

Solving Intraoperative Complications During Endovascular Repair of Late Contained Ruptured Aortic Pseudoaneurysm After Surgical De-coarctation: Case Report and Systematic Review of Literature.

We present a case of successful endovascular repair of late ruptured aortic anastomotic pseudoaneurysm following previous left subclavian artery-descending thoracic aorta bypass and concomitant emergency thoracic endovascular aortic repair (TEVAR) of complicated endovascular aortic de-coarctation never previously described is also presented. A review of the intraoperative, 30-day, and follow-up morbidity, mortality, and complications of TEVAR as endovascular treatment of late aneurysm/pseudoaneurysms after surgical aortic de-coarctation was also performed. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and following PICO model. A literature search was conducted on MEDLINE, PubMed, EMBASE, Cochrane Library, Google Scholar, Science Direct, and Web of Science using the words "tevar of late complication of aortic coarctation surgical repair" and "endovascular repair of anastomotic pseudoaneurysm in coarctation" up to June 17, 2022. Data were extracted from study documents about study design, patient's demographics and comorbidities, details about primary surgical repair, type of late complication, time between open surgery and occurrence of complications, details of the secondary endovascular procedure with technical success, early, and follow-up mortality and morbidity. A total of 18 papers were included with 78 patients (48 men, 69.5%). The most frequent type of primary open surgical repair was patch aortoplasty (46, 58.9%). Focusing on aneurysm and pseudoaneurysm as late complications, most of the patients were asymptomatic (45, 57.7%). All patients underwent TEVAR, 14 of them (17.9%) in urgent/emergent setting. The technical success was 98.7%, with 1 intraoperative death due to rupture of the aorta. In total, 31 patients out of 78 (39.7%) showed different complications in the immediate postoperative time, with type II endoleak being the most observed (8/31, 25.8%). The mean follow-up time was about 2 years (26.5 months, range 3-92). Overall, 30-day mortality was 2.6%. Complications occurred in 30 patients (39.4%), 23 of them resolved during the follow-up period. With the limit of low-quality data, TEVAR can be considered a safe and effective option for the treatment of late complications after open surgery for aortic coarctation, even in urgent settings. Different specialists have to face the technical complexities and risks related to treatment of late complications after surgical de-coartaction, which can be either surgical or endovascular, and depend on patient's ages. Although covered stents appear to have some protection from the development of stent fractures, doesn't provide complete protection from late aneurysm formation. In this setting, TEVAR may represent a valuable option, combining the advantages of the covered stent with those of a device that can cover a wider range of aortic length, especially in adult patients. This study shows thoracic endovascular repair can be considered a safe and effective option in clincal practice for the treatment of late complications after open surgery for AC, even in urgent settings.

Intermediate outcome for the single-stage surgical repair of aortopulmonary window associated with interrupted aortic arch.

Aortopulmonary window (APW) associated with an interrupted aortic arch (IAA) is a rare cardiac malformation with significant mortality and morbidity. The goal of this study was to report the intermediate outcomes of single-stage repair concentrating on the surgical techniques and postoperative reintervention for this rare cardiac lesion. Eleven patients were diagnosed with IAA-associated APW and underwent single-stage surgical repair at Vietnam National Children's Hospital. The APW anatomy types were types I, II and III in 1, 4 and 6 patients, respectively. The IAA morphology was type A in 9 patients and type B in 2 patients. The median age was 27 [interquartile range (IQR) 6-79] days, and the median weight was 3.5 (IQR 2.8-4.5) kg. The aortic arch was repaired using direct end-to-side tissue anastomosis in 7 patients, and patch aortoplasty was performed in 4 patients. Six patients underwent APW closure with an intra-aortic baffle, and 5 patients required right pulmonary artery detachment and reimplantation. One early death occurred. Four patients required reinterventions: 1 patient required reoperation due to aortic stenosis and 3 required balloon angioplasty for either recurrent aortic arch stenosis (n = 1) or right pulmonary stenosis (n = 2) with a mean follow-up time of 3.1 years (IQR 0.5-4.3 years). Single-stage repair of IAA-associated APW can be achieved with good survival outcomes in children. However, the need for repeat reintervention or reoperation remains high, and the growth of both the aorta and pulmonary arteries should follow carefully as the patient grows. VNCH-RICH-18-96.

Surgical Treatment of a Late Post-Coarctation Aortic Aneurysm

A 55 year old man treated when aged 12 with a Dacron patch aortoplasty for coarctation, presented with hoarseness. (A) Computed tomography angiography showed a 67 mm post-coarctation aneurysm, angulated hypoplastic aortic arch (AA), ectatic proximal left subclavian artery (LSA), thickened ligamentum arteriosus (LA), and bicuspid aortic valve (posterior view). Re-thoracotomy was performed through the left fourth intercostal space with lysis of tight adhesions. Aneurysmectomy with graft interposition (14 mm Dacron) and LSA revascularisation was performed (B). Banding of the proximal anastomosis was added owing to the very fragile AA wall. Post-operative hospitalisation was uneventful.Image 1

Aortic Arch Phenotypes in Double Outlet Right Ventricle (DORV)-Implications for Surgery and Multi-Modal Imaging.

Abnormal aortic arches (AAAs) cover a spectrum of malformations, including abnormal laterality, branching patterns, and flow-limiting narrowing, which themselves vary from tubular hypoplasia, through discrete coarctation, to complete interruption of the arch. Neonatal surgery within the first days of life is necessary for most of these morphologies. Patch aortoplasty is widely used as it can offer a good haemodynamic result, being tailored to each combination of presenting pathologies. Our study hypothesis was that arch malformations are frequent in DORV and exhibit a plethora of phenotypes. We reviewed 54 post-mortem heart specimens from the UCL Cardiac Archive, analysing morphological features that would potentially influence the surgical repair, and taking relevant measurements of surgical importance. AAAs were found in half of the specimens, including 22.2% with aortic arch narrowing. In total, 70% and 30% of narrow arches had a subpulmonary and subaortic interventricular defect, respectively. Z-scores were significantly negative for all cases with tubular hypoplasia. We concluded that arch malformations are a common finding among hearts with DORV. Surgery on the neonatal aortic arch in DORV, performed in conjunction with other interventions that aim to balance pulmonary to systemic flow (Qp/Qs), should be anticipated and form an important part of multi-modal imaging.

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Repair of pseudoaneurysm in extra-anatomic aortic arch bypass graft.

Surgery for aortic recoarctation in children less than 10 years old: A single-center experience in Siberia, Russia.

Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short-term outcomes of surgical management of recurrent coarctation and initial repair analysis. We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion (ACP) technique. Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end-to-end anastomosis in 15 (29%), and a tube interposition graft in 13 (25%) patients. The median age at initial correction and reintervention was 12 months and 9 years. The median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72.5% of patients were done via a left thoracotomy approach and 63% of patients had end-to-end anastomosis at initial surgery. Our study demonstrates that surgical repair of recurrent coarctation of the aorta using ACP technique can be performed safely and with excellent results.

Pseudoaneurysm following a neonatal coarctation repair; a dreadful complication.

Aneurysms of descending thoracic aorta following surgical repair of coarctation have been reported in literature. Almost always, they are seen in repairs involving prosthetic patch aortoplasty. We report a neonate who underwent resection and an extended end to end anastomosis repair of coarctation and subsequently developed a huge pseudoaneurysm at a 3-month follow-up. He underwent a repair of the same through a sternotomy approach under hypothermic low flow cardiopulmonary bypass. An autologous pericardial patch aortoplasty was done successfully.

Outcomes of Arch Reintervention for Recurrent Coarctation in Young Children.

To evaluate the outcomes of reintervention for postrepair recoarctation in young children. Between January 2011 and December 2020, all consecutive patients aged ≤3 years who were treated for postrepair recoarctation were included. Recoarctations were classified into two morphological types by three-dimensional imaging. Two methods, namely, surgical repair and balloon angioplasty (BA), were used to treat recoarctation. This study included 50 patients with a median age of 10.5 months (range, 2.0-36.0 months) and a mean weight of 9.3 ± 3.1 kg. Hypoplastic recoarctation occurred most frequently in patients who had undergone patch aortoplasty at initial repair (p = 0.001). No hospital mortality occurred, and all patients achieved an increased diameter (p < 0.001) and a decreased pressure gradient (p < 0.001) at the recoarctation site immediately after reintervention. The median follow-up time after reintervention was 3.5 years (range, 16.0 days-9.6 years). Late mortality occurred in four patients (8.0%): two in the surgical group and two in the BA group (chi-square test= 0.414, p = 0.520). There was no difference in arch reobstruction after reintervention between the surgical and BA groups (chi-square test = 1.383, p = 0.240). Recoarctation with a hypoplastic morphology was the leading risk factor for arch reobstruction after reintervention (hazard ratio, 6.552; 95% confidence interval, 2.045-20.992; p = 0.002). Reintervention for recoarctation has favorable early outcomes in young children. However, late mortality is not rare, and arch reobstruction is common during close follow-up. For young children, recoarctation with hypoplastic morphology is the leading risk factor for reobstruction, while the choice of reintervention method exerts little effect on the outcomes of arch reintervention.

Does age at aortic coarctation repair have an impact on left ventricle size and function?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Adults with repaired aortic coarctation (CoA) require lifelong follow-up due to late complications, including left ventricular (LV) myocardial dysfunction. Age at the time of CoA repair is an important prognostic factor in these patients (pts). Purpose To evaluate LV size, ejection fraction (EF) and global longitudinal strain (GLS) values using 2D speckle tracking echocardiography (STE) in a population of adult pts with repaired CoA and to assess the relationship between these echocardiographic parameters and age at the time of CoA repair. Methods Retrospective analysis of adult pts with repaired CoA, followed in a Grown Up Congenital Heart Disease Centre. Pts with hemodynamically significant concomitant cardiac lesions were ruled out. Epidemiologic and clinical data were obtained from clinical records. Transthoracic echocardiograms were reviewed in order to assess GLS using 2DSTE (Echopac Software, GE). Results The study population consisted of 63 pts (61.9% male), with a mean age of 35.3 years at the time of the echocardiographic evaluation. The mean age at the time of the CoA repair was 117 months (95% CI 89.8-144.1 months). Surgical repair was performed in 46 pts (73%): resection with subclavian artery flap aortoplasty (n = 21); patch aortoplasty (n = 15) and head-to-head anastomosis (n = 10). In 10 pts there was no data regarding the type of surgical repair. Seven pts (11.1%) were submitted to percutaneous intervention (6 with aortic stent implantation and 1 with balloon aortic angioplasty). Mean LVEF was 63.4% (CI 95% 55.6 – 71.2%) and mean LV end-diastolic diameter (LVEDD) was 50mm (CI 95% 43-57mm). Mean GLS was - 17.3 (CI 95% 14.8- 19.8), which is inferior to the mean normal values reported for the software used. Age at the time of CoA repair had a statistically significant positive linear relationship with LVEDD (r= 0.282; p= 0.026) and a linear negative relationship with both GLS (r= -0,29; p= 0.022) and LVEF (r= -0.33; p= 0.05). Conclusion Older age at the time of CoA repair was associated with increased LVEDD and decreased GLS and LVEF. Also, GLS may be an important tool for the identification of subclinical LV dysfunction in adult pts with repaired CoA.

Management of aortic arch hypoplasia in neonates and infants.

Surgical management of aortic arch hypoplasia (AAH) with associated intracardiac anomalies is a challenge in newborns. We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution. Medical records of 60 patients undergoing aortic arch reconstruction for AAH from 2014 to 2019 were retrospectively reviewed. Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median, 19.5 days). The patients were divided into two groups: Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, and Group 2 (37 patients) underwent single-stage total repair in addition to arch repair. All arch repair procedures consisted of an extended (to the midportion of the ascending aorta) patch aortoplasty. Postoperative early mortality occurred in 12 patients, eight in Group 1 (34.8%) and four in Group 2 (10.8%). There was an early survival advantage in Group 2 (p = .019). Recoarctation occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty: 7, reoperation: 4). On univariate analysis, risk factors associated with death were pulmonary artery banding (hazard ratio [HR], 0.44; confidence interval [CI], 0.09-2; p = .019), prematurity (HR, 4.67; CI, 1.34-16.18; p = <.001), preoperative mechanical ventilation support requirement (HR, 0.048; CI, 0.52-6.39; p = .048), and functional single ventricle (HR, 0.43; CI, 0.1-1.86; p = .006). The mean duration of follow-up was 21.9 ± 15.1 months, and there was no late death in either group. Single-stage repair of AAH with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results. The use of the patch augmentation technique in AAH is valid and associated with an acceptable incidence of recurrent arch obstruction.

Early evaluation of the aortic root after Nicks' procedure

Objective(s)To determine the influence of surgical techniques adopted to avoid suture line disruption, periprosthetic leakage, patch dislodgement, pericardial patch aneurysm formation, and the long-term stability of aortic root enlargement (ARE) during aortic valve replacement (AVR).MethodsOne hundred fifteen patients undergoing AVR or combined aortic and mitral valve replacements with Nicks' posterior ARE between 1997 and 2019 underwent long-term echocardiographic and angio-computed tomographic evaluation. Age was 11-72 years (AVR: median, 30; interquartile range, 21-47 years; AVR and mitral valve replacement: median, 27.5; interquartile range, 20-37.5 years). The aortotomy was closed using autologous pericardial patch and Teflon-buttressed sutures.ResultsHospital mortality was 1.7% (n = 2), with 4 (3.5%) late deaths. At a mean follow-up of 123.11 ± 77.67 months, the survival probability from Kaplan–Meier was 93.25 ± 0.03%. No cases of severe prosthesis–patient mismatch (PPM) were observed, and only 2 patients had moderate PPM. Median aortic root diameters at the level of sinus of Valsalva and sinotubular junction were 32 (29-35) mm and 33 (30-36) mm, respectively, at discharge, and were 33 (30-36) mm, and 33 (31-37) mm, respectively, at latest follow-up, with no cases of late pericardial patch aneurysm.ConclusionsARE is a safe adjunct to AVR in patients with a small aortic annulus to prevent PPM. Retention of a pericardial collar and Teflon-buttressed sutures is an expedient, safe, and effective technique in reducing bleeding at the enlarged ventriculo-aortic junction. Autologous pericardial patch aortoplasty is not associated with late aneurysm/pseudoaneurysm formation.

Surgical management of pediatric renin-mediated hypertension secondary to renal artery occlusive disease and abdominal aortic coarctation

BackgroundRenovascular hypertension (RVH) associated with renal artery and abdominal aortic narrowings is the third most common cause of pediatric hypertension. Untreated children may experience major cardiopulmonary complications, stroke, renal failure, and death. The impetus of this study was to describe the increasingly complex surgical practice for such patients with an emphasis on anatomic phenotype and contemporary outcomes after surgical management as a means of identifying those factors responsible for persistent or recurrent hypertension necessitating reoperation. MethodsA retrospective analysis was performed of consecutive pediatric patients with RVH undergoing open surgical procedures at the University of Michigan from 1991 to 2017. Anatomic phenotype and patient risk factors were analyzed to predict outcomes of blood pressure control and the need for secondary operations using ordered and binomial logistic multinomial regression models, respectively. ResultsThere were 169 children (76 girls, 93 boys) who underwent primary index operations at a median age of 8.3 years; 31 children (18%) had neurofibromatosis type 1, 76 (45%) had abdominal aortic coarctations, and 28 (17%) had a single functioning kidney. Before treatment at the University of Michigan, 51 children experienced failed previous open operations (15) or endovascular interventions (36) for RVH at other institutions. Primary surgical interventions (342) included main renal artery (136) and segmental renal artery (10) aortic reimplantation, renal artery bypass (55), segmental renal artery embolization (10), renal artery patch angioplasty (8), resection with reanastomosis (4), and partial or total nephrectomy (25). Non-renal artery procedures included patch aortoplasty (32), aortoaortic bypass (32), and splanchnic arterial revascularization (30). Nine patients required reoperation in the early postoperative period. During a mean follow-up of 49 months, secondary interventions were required in 35 children (21%), including both open surgical (37) and endovascular (14) interventions. Remedial intervention to preserve primary renal artery patency or a nephrectomy if such was impossible was required in 22 children (13%). The remaining secondary procedures were performed to treat previously untreated disease that became clinically evident during follow-up. Age at operation and abdominal aortic coarctation were independent predictors for reoperation. The overall experience revealed hypertension to be cured in 74 children (44%), improved in 78 (46%), and unchanged in 17 (10%). Children undergoing remedial operations were less likely (33%) to be cured of hypertension. There was no perioperative death or renal insufficiency requiring dialysis after either primary or secondary interventions. ConclusionsContemporary surgical treatment of pediatric RVH provides a sustainable overall benefit to 90% of children. Interventions in the very young (<3 years) and concurrent abdominal aortic coarctation increase the likelihood of reoperation. Patients undergoing remedial surgery after earlier operative failures are less likely to be cured of hypertension. Judicious postoperative surveillance is imperative in children surgically treated for RVH.

Patch aortoplasty and anatomical lung resection in a patient with aortobronchial fistula due to aortic psuedo-aneurysm

Aortobronchial fistula (ABF) is a rare and devastating complication, if left untreated. Its main clinical manifestation is hemoptysis, and there are no defined guidelines for its treatment yet. Herein, we present the case of a 74-year-old male who complained of back pain and hemoptysis. The patient was diagnosed with pseudo-aneurysm and ABF, and he underwent hybrid thoracic endovascular aortic repair. However, hemoptysis recurred. With patch aortoplasty and anatomical lung resection, successful management of ABF was achieved, with no relapse for 5years.

Modeling aortorenal perfusion in suprarenal coarctation repair

Suprarenal abdominal aortic coarctation (SAAC) is a congenital midaortic syndrome that develops owing to a developmental anomaly in the fusion of the embryonic dorsal aortae. This condition is associated with severe hypertension, which is usually the indication for intervention. Open surgery is the primary treatment and it typically involves thoracoaortic bypass (TAB), and less commonly patch aortoplasty (PA). Bypass to the visceral vessels has also been performed in conjunction with TAB or PA. The majority undergoing intervention for SAAC are children and adolescents; therefore, the benefits of surgical intervention must be weighed against the risks of surgery on the developing aorta.

Surgical management of Coarctation of the Aorta in the Pediatric Population: A fifteen-year experience

Coarctation of the aorta is one of the most commonly encountered congenital heart defects (CHD), in the pediatric population. It is defined as a hemodynamically significant stenosis of the descending aorta, typically at the site of insertion of ductus arteriosus. It has an estimated incidence of 4-6 cases per 100,000 births, accounting for 5-8% of all congenital heart defects [1-4]. According to The New England Regional Infant Cardiac Program (NERICP), coarctation of the aorta is the fourth most common defect requiring surgery during the first year of life [5]. It can present as an isolated lesion or coexist with other cardiac or extra-cardiac congenital defects. The most common one include bicuspid aortic valve, patent ductus arteriosus, ventricular septal defect, mitral stenosis, berry aneurysms in the circle of Willis [6-8]. Clinical presentation is heterogenous, varying from asymptomatic to congestive heart failure, acute pulmonary edema and cardiogenic shock, depending on the degree of coarctation, the development of collateral circulation and age at presentation [9]. During the neonatal period patients may present with circulatory collapse and pulmonary edema, reduced or absent peripheral pulses, tachypnea, lethargy and progressive metabolic acidosis [9-13]. In early childhood, they present primarily with symptoms of congestive heart failure (CHF) including tachypnea, irritability, sweating, feeding difficulties and failure to thrive [9-13]. In adolescence and adulthood patients may be asymptomatic, presenting with non-specific symptoms including exercise intolerance, fatigue and cramps in the lower limbs, recurrent headaches, epistaxis, vertigo, tinnitus, high blood pressure and difference in blood pressure between arms and legs and reduced or absent peripheral pulses [9-13]. Treatment options for coarctation of the aorta include both surgery and catheter-based procedures. Several surgical techniques have been developed including extended resection with end-to-end anastomosis, prosthetic patch aortoplasty, subclavian patch aortoplasty, interposition grafting and extraanatomic bypass grafting [9-11,13-18]. Catheter-based approaches include balloon angioplasty and stenting. The choice is based on the age at presentation, the type of coarctation, and the presence of associated anomalies, as well as other patient-specific characteristics.

P1494 Incidental finding of aortic aneurysm formation following 34 years of coarctation repair by dacron patch aortoplasty

Abstract Introduction Aneurysms are found following all types of surgical repair of aortic coarctation, especially after Dacron patch aortoplasty. We describe the finding of an aortic aneurysm in an asymptomatic 52-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 34 years earlier. Case report A 52-year male, smoker, hypertensive on medication He had previous history of surgical repair of aortic coarctation at age of 18 years . Repair was by Dacron patch aortoplasty. Since then, his regular follow up was unremarkable. Recently, he was referred for cardiac evaluation as a part of pre-employment general check-up. He was asymptomatic with no history of shortness of breath or chest pain. Physical examination revealed that the pulse in the left arm was reduced in volume in comparison to the right one. The heart sounds were essentially normal but a pericardial murmur was audible, perhaps reflecting residual collateral flow. Blood pressure was 156/83 mmHg in right arm and 142/81 in the left arm. Transthoracic echocardiography revealed mild left ventricular hypertrophy with normal global and regional contractility and an ejection fraction of 58%. Supra sternal window images showed dilatation of the three aortic arch branches. The distal portion of aortic arch just distal to origin of left subclavian artery was narrowed with a peak systolic gradient across of 34 mmHg. A cystic structure (1.7 cm x 1.9 cm) was visualized attached to the narrowed segment of the aorta, suggestive of a saccular aneurysm, (figures A&amp;B&amp;C). Computed tomography aortogram showed a narrow-necked aneurysm arising from the posterolateral aspect of the distal aortic arch (anticipated site of the coarctation repair graft anastomosis). A small laminated thrombus was also noted within. Aneurysm measured approximately 2.2 x 3.3 cm in its craniocaudal and anteroposterior dimensions respectively, with no evidence of aortic luminal compromise. (figures D&amp;E&amp;F). Management Aneurysmectomy was performed subsequently. Interposition polyester grafts were used to reconstruct the aortic arch and proximal descending aorta and to connect this aortic segment to the subclavian artery via a lateral thoracotomy. The postoperative course thereafter was uneventful. Conclusion: This is a rare insidious complication of Dacron patch aortoplasty that occurred after more than 3 decades, which highlights the importance of diagnostic imaging in the follow up of these patients Abstract P1494 Figure.