tipology:brief-report

numero rivista e pagine: HSR Proceedings in Intensive Care and Cardiovascular Anesthesia 2012; 4(2): 95-96
PDF version

Coarctation of the aorta

Authors: R. Prêtre*

Clinic for Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland

Corresponding author: * Corresponding author:
René Prêtre, MD
Clinic for Cardiovascular Surgery
University Hospital Zürich
Raemistrasse 100
Zürich CH 8091
E-mail: rene.pretre@kispi.uzh.ch

ABSTRACT

The surgical treatment of an aortic coarctation requires a resection of the stenotic area and direct suture of the aorta. An extended mobilization allows an enlargement of a hypoplastic distal aortic arch. In ductal dependent circulation, the distal aortic arch can be enlarged with a patch before tackling the coarctation itself. Postsurgical aortic arch stenoses often require a surgical intervention. Our preferred method is an anatomic correction with an enlargement plasty either on the concavity or on the convexity of the arch, depending on the local anatomy. An extra-anatomic bypass is also an option.

 

Keywords: coarctation, aortic arch, extended resection, enlargement plasty

Coarctation of the aorta is one of the most common diagnoses in congenital cardiac defects. It comes in an isolated form or in association with various obstructive lesions along the left side of the heart or with a perimembranous ventricular septal defect (VSD).
The diagnosis is mostly established in the neonatal period and hence the great majority of corrections are performed within two or three days after birth.
An extended resection [1, 2] is almost always possible at that time due to the particular elasticity of the aortic tissue allowing extensive mobilization of both segments of the thoracic aorta.
The risk of paraplegia is minimal as long as the cross-clamping of the aorta does not exceed 30 minutes [3].
Later in life, the repair may require an assisted circulation (a left heart bypass between the left atrial appendage and the thoracic aorta) to the lower body to avoid such a complication or other visceral ischemic lesions [4, 5].
Coarctation associated with a long, hypoplastic distal aortic arch is also repaired with a left thoracotomy without circulatory assistance in our center, but is preceded by an enlargement plasty of the roof of the distal arch [6]. The enlargement is performed first, with a patch of tanned pericardium, and with the use of ductal perfusion to avoid any visceral ischemia. The resection-anastomosis of the coarctation is performed after the plasty.
Since the establishment of a minimally invasive, muscle sparing and extrapleural approach to repairing coarctations [7], we have abandoned the single stage repair when a perimembranous VSD was associated. For us, the only consideration for a coarctation repair with a sternotomy is when enlargement of the distal aortic arch is not possible with regular cross-clamping (in the case of common carotid truncus, in some cases of arteria lusoria and very rarely in the case of particularly unfavorable anatomy of the arch). Banding of the pulmonary artery is not routinely performed in the regular cases, and the VSD is closed when signs of heart strain arise, usually a little before the regular time.
The extrapleural approach [7] has furthermore reduced the development of subsequent collaterals between the thoracic wall and the left upper lobe, and has proved a significant advantage in cyanotic univentricular hearts requiring subsequently a Fontan circulation.
Recoarctations refractory to balloon dilatation [8, 9] are handled in our center anatomically, with surgery. The choice of approach between a sternotomy and a posterior thoracotomy depends on the exact location of the residual stenosis. In a few patients, a combined approach – surgery and stenting – can also be considered. Only rarely have we performed an extra-anatomic bypass. Our preferred approach is through a sternotomy with enlargement of either the superior or the inferior part of the aortic arch, depending on the anatomy. In children, we have often used the anterior wall of the (dilated) pulmonary artery to enlarge the inferior part of the aortic arch [10]. This autologous patch has excellent elastic characteristics and holds the systemic pressure well, with no degeneration. The pulmonary artery wall is reconstructed with autologous pericardium. In older patients, we have simply used a regular patch for the arch enlargement. In many patients, the anatomy is favorable for a roof plasty of the aortic arch (a technically easier repair). We commonly transect the left common carotid artery to facilitate this enlargement, and reimplant it at the end of the reconstruction. Both techniques have led to excellent results with minimal residual stenosis. It is only in multiple redo procedures, or in very complex arch anatomy that we consider an extra-anatomic bypass between the ascending and the coeliac aorta [11, 12].

 

References

  1. Kaushal S, Backer C L, Patel J N, et alii. Coarctation of the aorta: midterm outcomes of resection with extended end-to-end anastomosis. Ann Thorac Surg. 2009; 88: 1932-1938.
  2. Backer C L, Mavroudis C, Zias E A, et alii. Repair of coarctation with resection and extended end-to-end anastomosis. Ann Thorac Surg. 1998; 66: 1365-1370.
  3. Baker E. Controversy about coarctation. Cardiol Young 2008; 18: 361-362.
  4. Fiore A C, Ruzmetov M, Johnson R G, et alii. Selective use of left heart bypass for aortic coarctation. Ann Thorac Surg. 2010; 89: 851-856.
  5. Wong C H, Watson B, Smith J, et alii. The use of left heart bypass in adult and recurrent coarctation repair. Eur J Cardiothorac Surg. 2001; 20: 1199-1201.
  6. Dave H, Rosser B, Reineke K, et alii. Aortic arch enlargement and coarctation repair through a left thoracotomy: significance of ductal perfusion. Eur J Cardiothorac Surg. 2012; 41: 906-912.
  7. Dave H H, Buechel E R, Pretre R. Muscle-sparing extrapleural approach for the repair of aortic coarctation. Ann Thorac Surg. 2006; 81: 243-8. Ann Thorac Surg. 2006; 81: 243-248.
  8. Fruh S, Knirsch W, Dodge-Khatami A, et alii. Comparison of surgical and interventional therapy of native and recurrent aortic coarctation regarding different age groups during childhood. Eur J Cardiothorac Surg. 2011; 39: 898-904.
  9. Zellers T M. Balloon angioplasty for recurrent coarctation of the aorta in patients following staged palliation for hypoplastic left heart syndrome. Am J Cardiol. 1999; 84: 231-233. A9.
  10. Kadner A, Dave H, Bettex D, et alii. Anatomic reconstruction of recurrent aortic arch obstruction in children. Eur J Cardiothorac Surg. 2004; 26: 60-65.
  11. Blasio A, Benussi S, Arcobasso L, Alfieri O. Extraanatomic Bypass for Recurrent Aortic Coarctation Involving the Arch and Replacement of the Ascending Aorta via Sternotomy. Innovations (Phila). 2006; 1: 167-168.
  12. Almeida de Oliveira S, Lisboa L A, Dallan L A, et alii. Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results. Ann Thorac Surg. 2003; 76: 1962-1966.

Cite as: Prêtre R. Coarctation of the aorta. HSR Proceedings in Intensive Care and Cardiovascular Anesthesia 2012; 4 (2): 95-96

 

Acknoledgments: We thank Anne Gale for carefully copy-editing the manuscript.

 

Source of Support : Nil.

 

Conflict of interest: None declared.

 

Presented at the 2nd Expert Forum of the Roland Hetzer International Cardiothoracic and Vascular Surgery Society, 11 February 2012, Freiburg, Germany