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J Thorac Cardiovasc Surg 2003;126:597-598
© 2003 The American Association for Thoracic Surgery
Brief communication |
a Department of Surgery (II), Sapporo Medical University School of Medicine, Hokkaido, Japan
Received for publication November 18, 2002; accepted for publication November 25, 2002.
* Address for reprints: Professor Tomio Abe, Chair, Department of Surgery (II), Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
tabe{at}sapmed.ac.jp
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In adults, coarctation of the aorta is usually accompanied by dilatation of the aorta at a site distal to the coarctation, and graft replacement of the aorta is therefore usually performed. Pathological study of coarctation has revealed that median necrosis of the aorta and aortic injury may occur as a result of crossclamping a portion of the aorta to the site of coarctation. Herein, we report a successful surgical repair of coarctation of the aorta by graft replacement using open anastomosis technique under the condition of deep-hypothermic circulatory arrest and a central cannulation technique. These techniques appear to be safe, and we recommend that they be used as a standard procedure for surgical repair of coarctation of the aorta in adults.
Clinical summary
A 57-year-old woman had been followed up for coarctation of the aorta (postductal type) and descending aortic aneurysm for 9 years. The size of the aortic aneurysm had increased to 55 mm, and pressure gradient between the arms and legs was 46 mm Hg at rest. Three-dimensional computed tomography confirmed the presence of a coarctation of the aorta just distal to the left subclavian artery, and the presence of a descending aortic aneurysm (Figure 1). Magnetic resonance imaging revealed the left Th11 intercostal artery to be an Adamkiewicz artery. A graft interposition of the coarctation and aneurysm of descending aorta was planned.
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The patient was placed in a left thoracotomy position, with the hips swiveled for femoral cannulation. The incision was performed through the fourth intercostal space. Tape was passed around the ascending aorta to assist cannulation. After exposure of the aortic aneurysmal segment, tape was also passed around the descending aorta at the level of Th9, then cardiopulmonary bypass (CPB) was initiated between a double-staged venous cannula inserted through the right femoral vein and an ascending aorta cannula, and core cooling was commenced. An arterial cannula was also inserted through the right femoral artery. After ventricular fibrillation of the heart, a venting tube was inserted through the left atrial appendage and the ascending aorta was crossclamped, and cold cardioplegia was performed to obtain a state of cardiac arrest. Circulatory arrest was achieved at a rectal temperature of 21.5°C. The descending aorta was opened, and the portions of the coarctation and aneurysm were resected. Then, a 22-mm woven double-velour Dacron graft (Hemashield Gold; Boston Scientific Corp, Natick, Mass) was anastomosed to the proxymal aorta with 3-0 polypropylene by an open proxymal technique. The incision of the proxymal aorta was extended toward the left subclavian artery to adjust the size of aortic orifice to the graft. The distal descending aorta was crossclamped during this process. After completion of proxymal anastomosis, the head and body were reperfused with a vascular clamp through the ascending aortic and right femoral arterial cannulas, respectively. Distal aortic anastomosis was performed with 3-0 polypropylene at the Th9 level during rewarming. Weaning from CPB was easy and the postoperative course was uneventful. There was no arterial pressure gradient between the arms and legs after the operation.
Discussion
Surgical repair of aortic coarctation has expanded to include resection with end-to-end anastomosis,1 prosthetic patch aortoplasty,2 subclavian flap aortoplasty,3 and aortic resection with graft replacement. Because further aortic growth is not a problem in adult patients, graft replacement or bypass is often used and produces the best results.4,5 As the aortic wall in the portion of coarctation was thought to be fragile in our case because of the median necrosis, we used an open proxymal anastomosis technique to avoid possible aortic injury caused by crossclamping.
The central cannulation technique6 is preferred for correction of postductal coarctation of the aorta to secure sufficient cerebral perfusion. In our case, this technique also had the advantage of preventing scattering of debris by the blood jet in an aortic aneurysm to cerebral blood flow. We prefer insertion of a venous cannula into the right atrium through the right femoral vein rather than insertion into the main pulmonary artery, as originally reported by Westaby and colleagues,6 because we have sometimes found that the wall of the main pulmonary artery is very fragile and thus susceptible to injury. We routinely insert a double-staged venous cannula through the right femoral vein in operations for descending aortic aneurysms and have experienced no technical problems.
In conclusion, our "modified" central cannulation technique and open proxymal anastomosis technique seem to be safe. This is an appropriate approach for surgical correction, and we recommend it as the standard approach for the coarctation of the aorta in adults.
References
This article has been cited by other articles:
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  Y. Fujisawa, K. Morishita, J. Fukada, Y. Hachiro, T. Saito, and T. Abe Strategy for Adult Aortic Coarctation Complicated by Coronary Artery Disease Asian Cardiovasc Thorac Ann, June 1, 2007; 15(3): e41 - e42. [Abstract] [Full Text] [PDF]
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 T. Ueda, S. Taguchi, Y. Inoue, and I. Kashima Hypothermic circulatory arrest through a left thoracotomy in a 12-year-old child with aortic coarctation Interactive CardioVascular and Thoracic Surgery, February 1, 2007; 6(1): 85 - 86. [Abstract] [Full Text] [PDF]
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 M. Ricci Repair of coarctation of the aorta J. Thorac. Cardiovasc. Surg., April 1, 2004; 127(4): 1224 - 1225. [Full Text] [PDF]
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