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Interact CardioVasc Thorac Surg 2008;7:170-172. doi:10.1510/icvts.2007.157685 © 2008 European Association of Cardio-Thoracic Surgery
One-stage repair of an aortic dissection and aortic coarctationRoyal Infirmary of Edinburgh, Edinburgh, UK Received 11 April 2007; received in revised form 9 October 2007; accepted 11 October 2007
*Corresponding author. Flat 1F2, 47 Great King St, Edinburgh, EH3 6RP. Tel.: +44-7946706945.
Ascending aortic dissection with aortic coarctation has a high mortality. There are few reports of successful surgical management of the combined condition. We report a case of a successful one-stage repair of type A aortic dissection with aortic coarctation, using an extra-anatomic bypass to connect the ascending to the abdominal aorta.
Key Words: Aorta; Dissection; Coarctation
A 29-year-old male presented with a 4-day history of severe central anterior chest pain. Drug history included cocaine use and Sildenafil for erectile dysfunction. Observations included BP 166/69, pulse 85 sinus rhythm, tachypnoeic 24/min and saturations 97% on air. Cardiorespiratory examination was normal. Electrocardiography revealed ST elevation in V2–6, I, II and aVL. Chest radiograph revealed non-specific changes. Biochemistry was normal. Haemoglobin was 126 g/l, leucocytosis of 12.8x109/l and C reactive protein 141 mg/l. His working diagnosis was pericarditis. Initial echocardiogram revealed a 1 cm pericardial effusion and 4.5 cm aortic root. Echocardiography three days later showed increasing aortic root diameter. There was a 40 mmHg systolic BP difference between his arms. Computerised tomography demonstrated a 8.1x6.8 cm ascending aorta. A dissection flap extended from the sinus of Valsalva to a pin-hole coarctation distal to the left subclavian artery, and into an ectatic inominate artery. There was a 2 cm pericardial effusion. Marked intercostal and internal mammary artery collateral formation supplied the descending thoracic aorta (Fig. 1).
At surgery, groin exposure revealed underdeveloped, weakly pulsatile femoral arteries. After heparinisation, the femoral and right subclavian arteries were used for bypass inflow perfusion of the lower and upper body, respectively. When these two pipes were connected in a Y arrangement for bypass, blood flowed rapidly from the right subclavian cannula into the bypass pipes and back into the femoral cannula, indicating the substantial gradient between the upper and lower body. Following midline sternotomy, there was evidence of significant pericarditis, and a grossly dilated, dissected aortic root. With right atrial return, bypass was commenced with cooling to 15 °C. A mitral left ventricular vent was inserted. Cross-clamp was applied and cold cardioplegia delivered retrogradely. The ascending aorta was opened and the entry point located above the right coronary ostium. The bicuspid aortic valve was preserved and resuspended, by means of a double layer of Teflon felt inside and outside the free margin of the proximal aorta. A size 32 mm Vascutek graft was anastomosed here and cardioplegia instilled into the neo-aortic root demonstrating haemostasis of the suture line and aortic valve competence. The distal ascending aortic anastomosis was made in a similar fashion to an open aorta under circulatory arrest. Circulation was recommenced. The descending aorta behind the heart was exposed but access was limited and it was technically impossible to graft a bypass tube here. A midline laparotomy incision allowed a new 20 mm Dacron tube graft to be anastomosed to the abdominal aorta in the region of the inferior mesenteric artery, tunnelled retroperitoneally behind the pancreas, posterior to the left lobe of liver, through a defect in the diaphragm, then around the right side of the heart and anastomosed to the side of the aortic root (Fig. 2).
The patient came off bypass with minimal inotropic support. Cardiopulmonary bypass, myocardial ischaemic and circulatory arrest time were 269, 104 and 24 min, respectively. The patient was extubated the following day. Intensive care unit stay was three days. Postoperative complications included atrial fibrillation requiring DC cardioversion, and a right subclavicular seroma. He was discharged on his thirteenth postoperative day on Atenolol and Amiodarone.
The literature contains 12 reports of ascending aortic dissection complicating aortic coarctation where surgery was performed. A third of these cases died postoperatively. Successful surgical correction of this condition was first described by Lawson and Fenn [1] in 1979 as a two-stage procedure, in which the coarctation was repaired before the dissected aorta. Sampath et al. [2] acknowledged that by correcting the coarctation first, proximal hypertension is reduced, therefore minimising risk of progressive dissection or rupture. However, the untreated aorta remains exposed to further complications whilst awaiting repair. Hovaguimian et al. [3] and Tesler and Tomasco [4] replaced the ascending aorta prior to coarctation repair. Though successful, leaving the coarctation untreated, risks a high and potentially dangerous afterload. Both authors believed that a combined approach would dramatically increase operative time and complication risk. It is clear that once the dissection has been repaired, tight BP control is essential. If too high, there is a risk of significant bleeding peri-operatively. If the blood pressure in the lower body is too low, spinal and renal perfusion will be at risk. It was essential to correct the coarctation at the time of surgery, repairing both conditions in one procedure. There are only four reports [5–8] of successful one-stage repairs of ascending aortic dissection complicating aortic coarctation. This approach was first described by Svensson in 1994 [5]. Three authors [5, 7, 8] created an extra-anatomic bypass using a tube graft to connect the ascending aortic graft with the abdominal aorta, as with our case. Paparella et al. [6] used a graft to replace the ascending aorta, aortic arch and isthmic coarctation in its entirety, specifically because of a hypoplastic arch. We electively decided not to replace the bicuspid aortic valve at this time, though valve replacement may subsequently prove necessary. When deciding which surgical procedure to undertake, one should consider the haemodynamic stability of the patient, optimal sequence and timing of the repair, the best surgical exposure, most appropriate arterial cannulation sites and conduct of bypass with adequate upper and lower body perfusion. This operation is a technical challenge in that conduct of bypass needs to be modified to ensure perfusion of the upper and lower body. When the gradient across the coarctation is high, femoral artery cannulation only delivers adequate blood flow to the lower body, and not to the upper body proximal to the coarctation [9]. In our case, this potential problem was resolved by also cannulating the subclavian artery. In conclusion, our one-stage technique represents a useful method of repairing combined aortic dissection and coarctation, particularly in situations where access to the descending thoracic aorta is limited. Cannulating the subclavian and femoral arteries allowed satisfactory perfusion of the whole body resulting in no significant postoperative complications. An extended sternotomy-laparotomy incision allowed good exposure throughout the procedure, and avoided a clamshell incision as the performing surgeon had minimal experience in this approach.
McKillop G, Consultant Radiologist, Royal Infirmary of Edinburgh, UK.
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Abstract
1. Case report
