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Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch
Eva Maria Delmo Walter1, Mariano Francisco Del Maria Javier1, Roland Hetzer1
1Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany.
Insights
Extra-anatomical bypass effectively treats complex aortic coarctation and hypoplastic aortic arch, showing safe and satisfactory long-term outcomes with no major complications. This surgical approach offers a reliable solution for challenging aortic arch conditions.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Pediatric Cardiology
Background:
- Aortic coarctation and hypoplastic aortic arch are complex congenital heart defects requiring surgical intervention.
- Recurrent coarctation and pseudoaneurysms pose significant challenges in surgical repair.
- Extra-anatomical bypass offers an alternative surgical strategy for complex aortic arch anomalies.
Purpose of the Study:
- To report the selection schemes for extra-anatomical bypass in complex, recurrent aortic coarctation and hypoplastic aortic arch.
- To detail the technical variations and long-term outcomes of this surgical approach.
- To evaluate the safety and efficacy of extra-anatomical bypass for challenging aortic arch conditions.
Main Methods:
- A retrospective review of 53 patients (mean age 13.2 years) with complex or recurrent aortic coarctation between 1989 and 2012.
- Surgical correction using various extra-anatomical bypass strategies, with or without extracorporeal circulation.
- Procedures performed via left lateral thoracotomy or combined sternotomy/laparotomy.
Main Results:
- No operative deaths, paraplegia, or abdominal malperfusion occurred in 53 patients.
- Significant reduction in systolic blood pressure (mean 60 mmHg) and elimination of pressure gradients.
- Excellent long-term outcomes with no reoperations, graft complications, or pseudoaneurysm formation over a mean follow-up of 18.3 years.
Conclusions:
- Extra-anatomical bypass is a safe and effective technique for complex and recurrent aortic coarctation.
- The procedure achieves satisfactory long-term results with a low complication rate.
- This approach provides a reliable solution for challenging aortic arch reconstructions.
Objectives:
Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch.
Methods:
Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9-23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmHg at rest and 180 ± 40 mmHg during exercise, with a mean pressure gradient of 80 ± 11.6 (range 40-120) mmHg.
Results:
Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10-26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmHg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon.
Conclusions:
Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.
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