J Thorac Cardiovasc Surg 2004;127:1224-1225
© 2004 The American Association for Thoracic Surgery
Repair of coarctation of the aorta
Marco Ricci, MD
Division of Cardiothoracic Surgery, Section of Pediatric Cardiac Surgery, University of Miami, Miami, FL 33136, USA
To the Editor:
I read with interest the article by Yamada and colleagues1 in which they describe a case of repair of coarctation of the aorta in a 57-year-old patient. Surgical correction entailed cardiopulmonary bypass using a "modified" technique of central cannulation and graft interposition using a Dacron conduit.1 Venous access was established through the right femoral vein, and arterial access was established by cannulating both the right femoral artery and ascending aorta. The proximal anastomosis between the graft and distal aortic arch was constructed using an "open technique" with complete circulatory arrest at 21.5°C. The duration of circulatory arrest was not mentioned, although it was presumably short because it corresponded to the time required to construct the proximal anastomosis. The distal anastomosis was performed while the head and body were being reperfused. This approach was favored to avoid the risks of crossclamping the fragile aorta, which would have been otherwise necessary with a conventional approach. The authors advocate the use of this technique, including circulatory arrest, as the standard approach for surgical correction of coarctation in adults.
Surgeons rarely encounter coarctation of the aorta in adults because fewer patients escape detection early in life, and those who do are often treated in adulthood with angioplasty and stenting.2 However, surgical repair can be difficult. Although spinal cord ischemia is not a common occurrence because of the presence of a well-developed collateral network, aortic crossclamping of the pressurized and fragile proximal aorta can pose a risk. Because the use of cardiopulmonary bypass may increase the safety of the operation, various strategies of cardiopulmonary bypass and techniques of cannulation have been used. Among these, the strategy described by Yamada and coworkers1 has the value of being applicable to extreme cases in which the aortic wall is particularly fragile and vulnerable to injury from crossclamping or during reoperations when clamping the aorta may not be feasible. Circulatory arrest has been used successfully by other groups for complex reoperations on the aorta after coarctation repair3,4 and in reoperations for re-coarctation.5 However, in some patients requiring primary repair, aortic clamping may be performed safely and effectively using alternative techniques and avoiding circulatory arrest. With the same strategy of cannulation and cardiopulmonary bypass support described by the authors, using mild systemic cooling, the aorta can be clamped at the distal arch during a very transient decrease in perfusion flow. Once the clamp is applied, full flow can be restored and maintained throughout the entire repair, thus providing continuous systemic, myocardial, and cerebral perfusion. Because circulatory arrest is not free from complications, advocating its routine use in every adult patient presenting with aortic coarctation, as proposed by the authors on the basis of a single observation, does not seem to be justified. Rather, this strategy should serve as a valuable adjunct in selected patients undergoing complex repairs or reoperations.
- Yamada A, Morishita K, Kawaharada N, Fukada J, Satsu T, Abe T. A safe strategy for surgical repair of coarctation of the aorta in an adult. J Thorac Cardiovasc Surg. 2003;126:597598[Free Full Text]
- Zabal C, Attie F, Rosas M, Buendia-Hernandez A, Garcia-Montes JA. The adult patient with native coarctation of the aorta: balloon angioplasty or primary stenting? Heart. 2003;89:7783[Abstract/Free Full Text]
- Rokkas CK, Murphy SF, Kouchoukos NT. Aortic coarctation in the adult: management of complications and coexisting arterial abnormalities with hypothermic cardiopulmonary bypass and circulatory arrest. J Thorac Cardiovasc Surg. 2002;124:155161[Abstract/Free Full Text]
- Ricci M, Rosenkranz ER, Salerno TA. Surgical strategy for repair of large pseudoaneurysms of the aortic isthmus. Eur J Cardiothorac Surg. 2001;20:12401242[Abstract/Free Full Text]
- Gudbjartsson T, Mathur M, Mihaljevic T, Aklog L, Byrne JG, Cohn LH. Hypothermic circulatory arrest for the surgical treatment of complicated adult coarctation of the aorta. J Am Coll Cardiol. 2003;41:849851[Medline]