Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral
Jan T Christenson1, Jorge Sierra, Dominique Didier
1Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland. jan.christenson@hcuge.ch
Insights
A temporary bypass during aortic coarctation repair protects against spinal cord injury in children with poor collateral circulation. This safe technique significantly reduces neurological complications.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Neurological Protection
Background:
- Surgical repair of aortic coarctation yields excellent outcomes.
- Spinal cord injury leading to paraplegia is a rare but serious complication.
- Preoperative assessment of collateral circulation is crucial for risk mitigation.
Purpose of the Study:
- To evaluate the efficacy of a temporary ascending to descending aorta bypass in children undergoing aortic coarctation repair.
- To assess the utility of magnetic resonance imaging (MRI) in identifying poor collateral circulation.
- To determine the safety and effectiveness of the bypass in preventing neurological complications.
Main Methods:
- Surgical correction of isolated aortic coarctation in 56 children (1990-2002).
- Introduction of preoperative MRI for collateral circulation assessment from 1998.
- Placement of a temporary polytetrafluoroethylene bypass (4-8 mm) when distal pressures were ≤25 mmHg or MRI showed absent collaterals.
Main Results:
- High correlation between intra-operative distal pressures and MRI findings.
- No neurological complications observed after implementing the temporary bypass.
- No bypass-related complications occurred.
- 96% freedom from restenosis.
Conclusions:
- Preoperative MRI accurately identifies poor collateral circulation in pediatric aortic coarctation.
- Temporary bypass effectively eliminates the risk of neurological complications in high-risk patients.
- The temporary bypass procedure is safe and easy to implement.
Abstract:
Aortic coarctation can now be repaired surgically with excellent results. Even though rare, injury to the spinal cord resulting in paraplegia remains a major concern. Preoperative evaluation showing the absence of collateral circulation is valuable in order to introduce protective actions. This report describes our experience using a temporary bypass from the ascending to the descending aorta bypass in children undergoing surgical correction of aortic coarctation in the setting of poorly developed collateral circulation. Between 1990 and 2002, we undertook direct surgical repair in 56 patients with isolated aortic coarctation, 20 as neonates, 11 as infants, and 25 during childhood. From 1998 onwards, we introduced preoperative evaluation of the collateral circulation with magnetic resonance imaging. From that time, we placed a temporary bypass from the ascending to the descending aorta, using a polytetrafluoroethylene tube of 4 to 8 mm diameter, whenever distal pressures were shown to be 25 mmHg or less after test clamping, or when magnetic resonance imaging revealed absence of collateral circulation. We found excellent correlations between the direct intra-operative measurements of distal pressure and the findings at magnetic resonance imaging. Following introduction of the temporary bypass, we observed no neurological complications, nor were there any complications related to bypass. Freedom from restenosis was 96%. Preoperative magnetic resonance imaging, therefore, can accurately visualize poor collateral circulation in children with aortic coarctation. The use of a temporary bypass can possibly eliminate the risk of neurological sequels following direct repair of coarctation in children with poorly developed collateral circulation. The temporary bypass is both easy to apply and safe.
