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This postoperative arteriogram shows an aortic valve prosthesis in place and the graft lying in a smooth contour around the right of the heart.
Source publication
In the previous 6-month period at the Texas Heart Institute, four patients requiring intracardiac surgery and coarctation repair have undergone ascending aorta to descending aorta bypass graft with satisfactory results. This technique permits one stage repair when coarctation occurs in association with intracardiac lesions and provides another meth...
Context in source publication
Context 1
... pulses were palpable in all pa- tients during the immediate postoperative period. No major complications occurred and no morbidity could be attributed to the combined procedure. No compression of the heart resulted from the course of the graft around the acute margin of the heart and right atrium (Fig. 2). The incidence of combined cardiac de- fects and recurrent stenosis at the site of previous coarctation repair suggests that similar situations precluding a more stan- dard surgical approach will the splanchnic nerves. Moreover, the su- praceliac position of the distal anastomosis could lead to erosion of the esophagogas- tric ...
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Aortobronchial fistula (ABF) in the setting of aortic coarctation repair is very rare but uniformly fatal if untreated. Endovascular stenting of the descending aorta is now the first-choice approach for ABF presenting with haemoptysis and offers a less-invasive technique with improved outcomes, compared with open repair. We report a case of late AB...
Citations
... Проксимальний анастомоз був сформований «кінець у бік» висхідної аорти. W. Powell та співавтори описали модифікацію цієї методики, в якій розташовували трансплантат навколо правого краю серця [20]. ...
... Following this, in 1983, Dr. Powell described a modification to Vijayanagar's technique, by which the graft was routed around the right margin of the heart through the space behind the inferior vena cava and in front of the right inferior pulmonary vein. Finally the graft was anastomosed proximate to the right lateral aspect of the ascending aorta (13). The advantages of extra-anatomic techniques rely on the complete avoidance of the manipulation of the coarctation segment and collateral arteries, which dramatically reduces the possibility of spinal cord injury and decreases the risk of catastrophic hemorrhage. ...
Background:
To explore surgical management of complex coarctation of aorta (COA) concomitant with intracardiac abnormality, in order to provide recommendations for safe and reliable treatment.
Methods:
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.
Results:
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.
Conclusions:
Simultaneous management of complex COA concomitant with intracardiac abnormality is a safe and reliable surgical method.
... Isolated coarctation of the aorta (CO-A) comprises a significant percentage of congenital heart diseases. 1 It is usually diagnosed and treated when discovered, most often during infancy or childhood, and more rarely in adulthood. Initial surgical repair is then performed through a left thoracotomy and consists of either resection of the stenotic site with end-to-end anastomosis or left subclavian artery (SCA) onlay patch aortoplasty. ...
Despite initial technical success in the treatment of coarctation of aorta, late recurrence and/or development of aneurysms and pseudoaneurysms frequently prompt reintervention. The authors hereby present such a patient whose management required more than a single intervention to treat his complex anatomy, and they discuss the therapeutic alternatives under similar circumstances.
... С тех пор этот метод, модифицированный W. Powell и соавт. [9] с расположением шунта вдоль правого края сердца, часто используется при коррекции сочетанного поражения аорты, пороков клапанов и т.д. [8]. ...
... Extra anatomic bypass grafts from the ascending to descending aorta are used formerly following different routes around the cardiac structure for the repair of coarctation accompanied by a congenital or an acquired heart disease in single stage procedure. 4) 5) In this paper, we will share our surgical experience in 7 adult patients with previously uncorrected, postductal aortic coarctation ( Fig. 1) accompanied by a congenital or an acquired heart disease necessitating repair, and who have underwent a single stage procedure through a median sternotomy. ...
... We led the extra anatomic bypass graft around the right lateral aspect of the heart in 3 patients but its course was above the IVC in 2 cases whereas under IVC in 1 of our patients and proximal anastomosis was achieved on the right lateral aspect of the ascending aorta. 5) The route of the extra anatomic bypass graft around the cardiac structure determines the risks of itself. The length of the graft leading around the left margin of the heart is significantly shorter, so possibility of graft kinking and compression on the surrounding tissues especially in the period of adolescence and childhood 14) seems to be less than the graft coursing around the right lateral aspect of the heart. ...
BACKGROUND AND OBJECTIVES:
Coarctation of the aorta in adulthood is generally associated with other cardiovascular disorders requiring surgical management. An extra anatomic bypass grafting from the ascending to descending aorta by posterior pericardial approach via median sternotomy could be a reasonable single stage surgical strategy for these patients.
SUBJECTS AND METHODS:
Seven male patients aged between 14-41 years underwent an extra anatomic bypass grafting for coarctation repair concomitantly with the surgical management of the associated cardiovascular disorders via median sternotomy. Preoperative mean systolic arterial blood pressure was 161.8±24.5 mmHg, although the patients were under treatment of different combinations of antihypertensive agents. Additional surgical procedures were: aortic valve replacement (n=4), ventricular septal defect (VSD) closure (n=2), ascending aortic replacement (n=3) and Bentall procedure (n=1). None of our patients have been previously diagnosed or operated on for coarctation. Data were evaluated during their hospital stay and in post-operative follow-up.
RESULTS:
The post-operative course was uneventful in all but one patient was re-operated on due to bleeding. There was neither mortality nor significant morbidity during the in-hospital period and all patients were discharged within 5-9 (mean: 6.3±1.5) days. The mean follow up period was 71.83±23 months (range: 23-95 months). Unfortunately one of our patients could not be contacted for a follow up period because of invalid personal data.
CONCLUSION:
Coarctation of the aorta in adulthood associated with other cardiovascular disorders can be operated on simultaneously via an extra anatomic bypass grafting technique with low morbidity and mortality.
... The proximal anastomosis was made to the left aspect of the ascending aorta [1]. Since then, this technique was modified by Powell [13], who routed the graft around the right margin of the heart and the proximal anastomosis was made to the right aspect of the ascending aorta. Connolly has placed the graft between the inferior vena cava and the right inferior pulmonary vein, which keeps the graft in a posterior location avoiding compression of the right atrium [1]. ...
... Edie and colleagues [16] and Wukasch and colleagues [17] first described bypass of the aorta through a median sternotomy. Vijayanagar and colleagues [18] described aortic bypass posterior to the heart, which was further modified by several authors, including Sweeney and colleagues [3], Powell and colleagues [19], and Robicsek and colleagues [20]. Although some authors describe the possibility of performing ascending-descending aortic bypass without the use of the heart-lung machine, we prefer to use it because it allows maintenance of adequate perfusion pressure and hemodynamic stability during manipulation of the heart. ...
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 in 1.
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.
... Powell et al. described a modification of this technique, which routed the graft around the right margin of the heart [5]. The prevalence of recurrent coarctation varies widely from 7 to 60% of operated coarctations and as shown by the reported data, the incidence of aortic arch hypoplasia in infants undergoing operations for aortic coarctation accounts for 70% [6]. There is a tendency in the literature to repair aortic recoarctation by using the extra-anatomic technique, because of its relative easiness and smaller dissection of adhered planes, which might lead to lesions in the aorta or its adjacent structures [7]. ...
... There is a tendency in the literature to repair aortic recoarctation by using the extra-anatomic technique, because of its relative easiness and smaller dissection of adhered planes, which might lead to lesions in the aorta or its adjacent structures [7]. In this respect, extraanatomic ascending-to-descending aortic bypass, however,does not need local dissection of adhesions and the risk of injury to adjacent anatomical structures or the diseased aorta, nor cross-clamping of the diseased aortic segment,nor CPB [3,6]. The access was performed with heart mobilization and heart traction. ...
We report the case of a 9-month-old patient presenting for redo aortic arch surgery because of recoarctation. In present case, ascending-to-descending aortic bypass via median sternotomy was performed without cardiopulmonary bypass with good result. In spite of the fact that the different surgical and intervention treatment options of aortic coarctation are quite satisfactory, a certain group of patients need reoperation because of recoarctation. The recoarctation repair of the aorta with the extra-anatomic aortic bypass is considered a low-risk procedure with high success rate.
... They performed this procedure through a single median sternotomy and used a tube graft for extra-anatomic bypass which placed around the left margin of the heart. Later Powell et al. [5], reported a modification of this procedure, in which the graft has been placed around the right margin of the heart. Since the initial description, several reports demonstrated successful outcome of ascending-to-descending aortic bypass [1,4,6]. ...
A variety of approaches and surgical techniques have been proposed for the management of complex form of aortic coarctation. When there is an additional cardiovascular disorder that requires surgical correction it is preferable to correct both lesions through the same incision simultaneously. In this paper, we describe the technique of ascending-to-descending aorta bypass grafting performed through the median sternotomy and simultaneous additional cardiovascular disorders repair in a case who had complex aortic Coarctation.
... In the next five patients, perfusion was maintained by the ascending aorta and the graft, which was anastomosed to the descending aorta. The size of the graft was determined by the diameter of the descending aorta at the diaphragmatic level [9,10], which was 16,18,20,22 and 24 mm in one, two, three, three and two patients, respectively. The graft was placed retrocavally in seven patients, whereas it was placed antecavally in four patients (Figs 2 and 3). ...
... It is not appropriate before adulthood, because anastomotic dehiscence might occur during the growth period [5]. This technique was modified by Powell et al. [16], according to whom, passing the graft through the right side of the heart not only helps to avoid damage of left hilar vessels and phrenic nerve but also facilitates easy dissection during reoperation. Although perioperative morbidity is lower, bleeding caused re-exploration is approximately 10% in the extraanatomical bypass [17]. ...
OBJECTIVES
Coarctation accompanied by cardiac lesions is a complex clinical situation due to the presence of two different pathologies that necessitate surgical treatment. An individual strategy, according to the severity of the disease, is important to reduce perioperative mortality and morbidity.METHODS
We report here on 25 patients with coarctation accompanied by cardiac lesions who were treated by various surgical approaches. Coarctation and associated disease were treated in 14 patients in a single stage by an ascending-to-descending bypass (n = 11) or by a hybrid procedure (n = 3). The remaining 11 patients underwent a two-stage operation for their treatment. Six of these 11 patients who had coronary artery disease or signs of congestive heart failure were first operated for their cardiac disease, whereas in the remaining five patients, who did not have any congestive signs, coarctation repair was performed first.RESULTSAll the patients were male, between the ages of 20 and 24 years, except for one 45-year-old woman. The mean cross-clamp times, cardiopulmonary bypass times and operation times were 52 ± 14.5, 102.3 ± 28.5 and 174 ± 24.8 min in the extra-anatomical bypass group; 29.8 ± 11.7, 55.5 ± 17.6 and 116 ± 22 min in the two-stage groups and 49 ± 19.8, 63 ± 18.7 and 159 ± 21.3 min in the hybrid patients, respectively. One patient who underwent extra-anatomical bypass died on the 14th postoperative day. There were no events during the follow-up period for the other patients. Also, there were no gradients between the extremities and no graft-related complications.CONCLUSIONS
As a consequence of the progress in the development of endovascular techniques, hybrid treatment is becoming a more popular option for the treatment of coarctation accompanied by cardiac diseases. Two-stage procedures and extra-anatomical bypass might be alternative techniques if endovascular procedures are contraindicated or failing.
