Endoarch Repair of Ruptured Extra-Anatomic Ascending to Descending Bypass Graft in Hypoplastic Arch With Coarctation

Hypoplastic arch and residual coarctation are treated with ascending to descending extra-anatomic bypasses and are challenging to manage.

A 36-year-old woman with several sternotomies had undergone ascending to descending extra-anatomic bypass as a neonate. She experienced blunt force trauma to her chest, and significant delay in diagnosis led to decompensation. A nondisplaced fracture lacerated the aortic graft and led to a contained rupture and bacteremia. She underwent left thoracotomy and complex thoracic endovascular aortic repair. Six weeks of antibiotics and careful conservative management led to a safe outcome.

Management of a ruptured extra-anatomic bypass in the setting of bacteremia with thoracic endovascular aortic repair is controversial. Given multiple prior sternotomies, the degree of required tissue debridement, and anticipated lifelong antibiotic suppression, an initial endovascular approach seemed warranted. Unconventional approaches to complex adult congenital heart disease (ACHD) lesions are necessary to increase longevity and mitigate disease.

Patients with ACHD require early recognition with a high index of suspicion. Endovascular repair in ACHD arch pathology should be considered.