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2010 • Cilt: 2 • Sayı: 2 • 21-24

 

 

 

RE-TORAKOTOMİ RE-KOARKTASYON VE HİPOPLASTİK AORT ARKUSUNU DÜZELTMEK İÇİN UYGUN BİR YÖNTEM Mİ?

 

IS RE-THORACOTOMY CONVIENENT APPROACH IN CORRECTING RE- COARCTATION AND HYPOPLASTIC AORTIC ARCH?

  

Ahmet SARITAŞ, Kanat ÖZIŞIK, Ayşenur PAÇ, İrfan TAŞOĞLU, Şeref Alp KÜÇÜKER, Mustafa PAÇ

 

ÖZET

 

Dokuz yaşında 24 kg erkek hasta re-aort koarktasyonu ve aortik ark hipopla- zisi cerrahisi için hastanemize başvurdu . Hastaya 4 yıl önce reseksiyon ve uç uca anastomoz tekniği ile aort koarktasyonu onarımı yapılmıştı. Bilgisayarlı tomografi anjiyografi’de eski tamir bölgesinde  belirgin daralma görüldü ve aortik ark hipoplazisi teyit edildi. Sol re-torakotomiden  sonra, aort devam- lılığını sağlamak için bir Dacron yama yerleştiridi. Ameliyat sonrası dönemi sorunsuz geçiren hasta ameliyatın yedinci gününde  taburcu  edildi. Post- operatif dönemde yapılan kontrol bilgisayarlı tomografi anjiyografi’de greftin açık olduğu izlendi.

Anahtar kelimeler: Aort koarktasyonu, aortik ark hipoplazisi, cerrahi, re- torakotomi

ABSTRACT

 

A nine-year-old boy weighing 24 kg referred to our hospital for surgical treatment of re-coarctation of the aorta and aortic arch hypoplasia. He had a history of resection of coarctation of the aorta with end-to-end anastomo- sis 4 years before. Computerized tomography angiography of the chest re- vealed obvious narrowing at the repaired site and confirmed the aortic arch hypoplasia. Following a left re-thoracotomy, a Dacron patch graft was used to restore aortic continuity. The postoperative course was uneventful and the patient was discharged on the seventh postoperative day. Post-operative control computerized tomography angiograhy confirmed the patency of the patch plasty .

Key words: Aortic coarctation, aortic arch hypoplasia, surgery, re-thoracot- omy

 

INTRODUCTION

 

Re-coarctation of the aorta (re-CoA) is not uncom- mon and is dependent on age at first operation, anato- my of the aorta, length of the abnormal tissue resected and the type of surgical procedure performed (1). The presence of a aortic arch hypoplasia (AAH) has been identified as one of the most important risk factor for reintervention in patients with CoA. One reason fort his may be underdiagnosed AAH and consecutive less aggressive treatment at primary surgery. Re-CoA may be difficult to manage when associated with tubular AAH, calcification and   tissue adhesives. In case of

concomitant AAH, deep hypothermic circulatory ar- rest is needed for augmentation of re-CoA, which ex- pose patients to increased cerebrovascular risks (2). In this patient, following a left re-thoracotomy, a Dacron patch graft was used to restore aortic continuity.

 

CASE REPORT

 

A nine-year-old boy weighing 24 kg referred to our hospital for surgical treatment  of re-CoA and AAH. Physical examination  was completely normal  except both  femoral and  left upper  extremity  pulses were weak. Four years before, he has been operated for CoA

 

 

Geliş Tarihi/Received: 23/01/2010  Kabul Tarihi/Accepted: 07/03/2010

 

İletişim:

 

Kanat Ozisik, MD

Birlik mah. 450. Cad.Vadi Apt. No:107/12 06550 Ankara- TURKEY

Tel: +90-505- 2901885 Fax: +90-312-3170353 E-mail: sozisik2002@yahoo.com

 

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through a left lateral thoracotomy in another center. A

15-mm segment of narrowed isthmus was resected and the descending thoracic aorta was pulled superiorly and directly anastomosed to the proximal part of of the aortic arch.

Electrocardiogram showed normal  sinus rhythm. Echocardiography demonstrated  AAH between bra- chiocephalic artery and left subclavian artery, and re- CoA with a mean gradient of 40 mmHg at the region where surgery had been previously performed (Figure

1A). The aortic valve was bicuspid. Cardiac catheterisa- tion and angiograhy also demonstrated a small trans- verse aortic arch after brachiocephalic artery and di- lated descending thoracic aorta.

 

 

 

Figure 1A- Preoperative echocardiography demons- trates re-CoA and AHH with a gradient of 40 mmHg.

 

 

Computerized  tomography  (CT)  angiography  of the chest revealed obvious narrowing at the repaired site and confirmed the AAH. Subclavian artery was demonstrated as orginating from the descending aorta beyond the hypoplastic segment (Figure 1B).

Elective surgical  treatment   of  the  re-CoA  was planned  and extreme care was taken for the dissection of the distal aortic arch and the proximal descending aorta because of the possible increased friability of the arterial wall and adhesions through a redo left thora- cotomy. The left common carotid artery and the sub- clavian artery were gently clamped and the proximal descending artery and aortic arch were cross-clamped between the brachiocephalic artery and the left com- mon carotid artery. A longitudinal incision was per- formed in the concavity of the aortic arch (across the re-CoA segment). He underwent  aortic enlargement with a perpendicular Dacron patch in order to increase vertical distensibility.

 

 

 

 

Figure 1B- Preoperative CT angiography showing re- CoA segment and diffuse stenosis of the AAH.

 

 

Once the repair of re-CoA and AAH was complet- ed, the aorta was deaired, the clamps on the arch arter- ies were removed and normal perfusion was resumed. Following deaeration clamps were released. Pulasatile blood flow was palpated in the descending thoracic aorta, distal to the patch plasty. The blood flow of right carotid artery was satisfactory therefore the shunt was not used. Blood pressure measured intra-operatively at proximal and distal segment showed no gradient across the corrected re-CoA and early follow-up echocardio- grams demonstrated  a harmonious  reconstruction  of the aortic arch and an unobstructed blood flow (Figure

2A). Blood pressure gradient between the right upper extremity and bilateral lower extremities reduced to

10 mmHg. Post operative control CT angiograhy con- firmed the patency of the patch plasty and success of the operative procedure (Figure 2B).

 

DISCUSSION

 

Backer et al. have reported that the rate of re-CoA after extended end to end anastomosis is 4% to 23%(3). In this situation, the procedure of choice is percuta- neous balloon dilatation and stenting; however, with presence of calcification, tissue adhesives and diffuse

2010 • Cilt: 2 • Sayı: 2 • 21-24         23

 

 

Figure 2A- Dacron Patch plasty with no stenosis and gradient showed by  postoperative  echocardi- ography.

 

 

Figure 2B- Postoperative CT angiography showing an excellent result after insertion of a Dacron patch plasty.

tubular AAH this approach may not be recommended

(4).

The best surgical repair  management  of re-CoA and AAH is controversial in children. Prosthetic patch aortoplasty is a safe operation. The mortality rate and incidence of paraplegia after patch aortoplasty are ex- tremely low (5). The operative mortality in several se- ries ranges from 0% to 10% (6,7). The technique avoids extensive dissection and prolonged cross-clamp time that may be required for CoA resection and end to end anastomosis. The collateral vessels are all preserved and

do not require ligation or division. The anastomosis is always tension free and quite easy to perform. Dacron patch aortoplasty is our procedure of choice because it provides excellent relief of CoA with a very low mor- tality rate, a low re-CoA rate. Long-term follow up is needed to allow a more  definitive comparison  with other established treatment modalities.

Surgery is usually performed via sternotomy and distal exposure of the aorta is limited to the isthmic re- gion. In surgical treatment of long segment restenosis with sternotomy possible difficulties are a need for dis- tal extension of the patch and inefficient mobilization of the descending aorta. In our case, exposure through a left re-thoracotomy was considered for local dissec- tion of adhesions with a risk of injury to adjacent ana- tomical structures or the diseased aorta.

The simple implantation of an extra-anatomic by- pass has resulted in good results and accepted as a safe surgical approach in adults (2,8). Long term results of this repair and the consequences to cardiac physiol- ogy are, however, unknown. Major limitations of as- cending to descending aortic bypass are the age of the patient and the size of the aorta (9). We believe that this approach is not indicated in children and infants. Furthermore, a left thoracotomy approach may be ap- plicable for redo surgery in this age group, because extra-anatomic bypass methods may be not enough for a growing child at later decades.

On the other hand, sternotomy was spared for a late aortic valve intervention which may secondarily occur because of a bicuspid aortic valve, in this patient.

 

REFERENCES

 

1.  Kappetein AP, Zwinderman AH, Bogers AJ, Rohm- er J, Huysmans HA. More than thirty-five years of coarctation repair. An unexpected high relapse rate. J Thorac Cardiovasc Surg 1994;107:87-95.

2.  Berdat PA, Göber V, Carrel T. Extra-anatomic aor- tic bypass for complex (re-) coarctation and hypo- plastic aortic arch in adolescents and adults. Inter- act Cardiovasc Thorac Surg 2003;2:133-7.

3.  Backer CL, Mavroudis C, Zias EA, Amin Z, Weigel TJ . Repair of coarctation with resection and ex- tended end-to-end  anastomosis. Ann Thorac Surg

1998;66:1365-70.

4.  Magee  AG,  Brzezinska-Rajszys G,  Qureshi  SA, Rosenthal E, Zubrzycka M, Ksiazyk J,  et al. Stent implantation  for aortic coarctation and recoarcta- tion. Heart 1999;82:600-6.

5.  Backer CL, Paape K, Zales VR, Weigel TJ, Mav- roudis  C. Coarctation  of the  aorta.  Repair with

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