Two-stage successful surgery in an aortic coarctation case operated initially for ascending aortic aneurysm / Oncelikli olarak assandan aort anevrizmasina mudahale edilen aort koarktasyonlu bir olguda iki evreli basarili cerrahi tedavi.Introduction
Aortic coarctation is a serious pathology required surgical treatment. About 50% of uncorrected isolated aortic coarctation cases are lost up to the age of 10, only 10% may reach the age of 50 (1). The most common reason for death from untreated aortic coarctation is the aneurysm or rupture of aorta or side branches with a rate of 23% (1). Aortic insufficiency resulting from annuloaortic ectasia and ascending aortic aneurysm together with aortic coarctation rarely occur, and surgical treatment is difficult. It is very important to decide whether surgical operation will be of one and two stage, and to determine intraoperative strategy.
Aortic coarctation is a congenital vessel disease that can cause such complications as myocardial infarction, congestive con·ges·tive
Of or characterized by congestion.
pertaining to or associated with congestion. See also congestive heart failure. cardiac failure, infective endocarditis, aortic aneurysm, aortic dissection or rupture and intracranial bleeding as a result of present resistant hypertension in adult age (2).
The aneurysm of the ascending aorta or dissecting aneurysm is a life-threatening complication of aortic coarctation. The incidence of aortic dissection and aneurysm in patients with coarctation of the aorta Coarctation of the Aorta Definition
A defect that develops in the fetus in which there is a narrowing of the aortic arch, the main blood artery that delivers blood from the left ventricle of the heart to the rest of the body. is well known (3); however, the reported cases of surgical correction of this condition are very few (3, 4).
Studies report various operations done when aortic aneurysm (1, 2, 4) or aortic dissection (5) occur together with aortic coarctation. These combined conditions are usually treated by one or two-stage surgery when aortic dissection exists, and the first step involves emergency repair of the aortic dissection. Subsequently, coarctation coarctation /co·arc·ta·tion/ (ko?ahrk-ta´shun) narrowing.
coarctation of aorta a local malformation marked by deformed aortic media, causing narrowing of the lumen of the vessel. repair is undertaken at a later date. But if there is ascending aortic aneurysm in addition to aortic coarctation without aortic dissection, the first repair must be performed for aortic coarctation. In our patient, initially the pathology of ascending aorta was operated because of dissection suspicion although aortic aneurysm, and aortic coarctation were repaired later.
A 33-year-old man was admitted to our unit for dizziness and sudden onset of retrosternal, constrictive constrictive
restricting movement or dilatation of an organ. pain that suggested an acute cardiac problem. On clinical examination, a 3/6 systolic murmur was heard in the aortic area. He have not been diagnosed cardiac disease, reporting only a recent diagnosis of hypertension.
The patient was conscious, pale, sweaty, restless, and agitated. His jugular veins were distended distended Medtalk Enlarged, bloated. Cf Nondistended. ; the blood pressure in his upper extremities was 220/100 mmHg. The carotid and radial pulses existed and were symmetrical, whereas femoral pulses were absent. Chest radiography, performed at the bedside, demonstrated middle mediastinal mediastinal /me·di·as·ti·nal/ (-as-ti´n'l) of or pertaining to the mediastinum.
of or pertaining to the mediastinum. widening, and evidence of bilateral rib notching, and electrocardiography electrocardiography (ĭlĕk'trōkärdēŏg`rəfē), science of recording and interpreting the electrical activity that precedes and is a measure of the action of heart muscles. showed sinus bradycardia with left ventricular hypertrophy left ventricular hypertrophy Cardiology Enlargement of the left ventricle often linked to the prolonged hemodynamic stress of CHF, characterized by myocardial cell hypertrophy, ↑ left ventricular wall thickness, ↓ ventricular compliance, ↑ . Transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall.
Across or through the thoracic cavity or chest wall. and transesophageal echocardiography demonstrated minimal presence of fluid in the pericardial cavity, dilated ascending and aortic root (approximately 7 cm), advanced aortic valvular valvular /val·vu·lar/ (val´vu-ler) pertaining to, affecting, or of the nature of a valve.
Relating to, having, or operating by means of valves or valvelike parts. incompetence, and signs suspicious for intimal intimal
pertaining to or emanating from vascular intima.
irregular mineralized masses covered by endothelium and protruding into the lumen of small arteries and arterioles of horses, especially in the intestinal flap in the ascending aorta. However, this image in echocardiography Echocardiography Definition
Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart muscle. Ultrasound waves that rebound or echo off the heart can show the size, shape, and movement of the heart's valves and also revealed artifact image. Computerized tomography (CT) of the chest revealed an aneurysm of the ascending aorta, and a coarctation of the descending aorta (Fig. 1). The interscapular and chest pain increased after one hour after arrival to hospital. Because ascending aorta was very large, and although the image in echocardiography resembled artifact, there was a probability of dissection and accordingly a higher risk of rupture, and the patient's clinical condition deteriorated so dramatically that he was taken immediately to the operating room. After median sternotomy, the pericardium pericardium: see heart. was opened. It was stretched because of very large ascending aorta and small amount of fluid. The aneurysmal ascending aorta was thin but not discolored dis·col·or
v. dis·col·ored, dis·col·or·ing, dis·col·ors
To alter or spoil the color of; stain.
To become altered or spoiled in color. . The femoral femoral /fem·o·ral/ (fem´or-al) pertaining to the femur or to the thigh.
Of or relating to the femur or thigh. and axillary artery cannulations were made to protect spinal and cerebral regions. During operation, perfusion pressure related with femoral and axillary ax·il·lar·y
Relating to the axilla.
Located in or near the armpit.
Mentioned in: Mastectomy
of or pertaining to the armpit. cannulation can·nu·la·tion or can·nu·li·za·tion
Insertion of a cannula.
introduction of a cannula into a tubelike organ or body cavity. was monitorized and the pressure was kept above 50 mmHg. Venous drainage was established with a single "two-stage" venous cannula cannula /can·nu·la/ (kan´u-lah) a tube for insertion into a vessel, duct, or cavity; during insertion its lumen is usually occupied by a trocar.
can·nu·la or can·u·la
n. pl. placed into the right atrium, and cardiopulmonary bypass (CPB CPB
see cardiopulmonary bypass.
CPB Cardiopulmonary bypass. See Port-Access cardiopulmonary bypass. ) was routinely instituted. The aneurysm was limited to the ascending aorta. The ascending aorta was cross-clamped and incised transversely. There was no dissection in ascending aorta. The sinuses of Valsalva were abnormal, they were suspended, and the coronary ostia Ostia (ŏs`tēə), ancient city of Italy, at the mouth of the Tiber. It was founded (4th cent. B.C.) as a protection for Rome, then developed (from the 1st cent. B.C.) as a Roman port, rivaling Puteoli. were displaced. The aortic valve was bicuspid bicuspid /bi·cus·pid/ (-kus´pid)
1. having two cusps.
2. pertaining to a mitral(bicuspid) valve.
3. premolar tooth.
adj. , with partially fused, thickened, and calcified Calcified
Hardened by calcium deposits.
Mentioned in: Heart Valve Repair leaflets. The aortic valve was excised, and the segment of the ascending aorta comprising the aneurysmal part was resected. The patient was performed modified Bentall procedure as described by Yakutetal (6). The anastomoses were reinforced with gelatin resorcinol resorcinol /re·sor·ci·nol/ (re-zor´si-nol) a bactericidal, fungicidal, keratolytic, exfoliative, and antipruritic agent, used especially as a topical keratolytic in the treatment of acne and other dermatoses. glue and Teflon strips. At the end of the procedure the patient was easily weaned off CPB; CPB, and cross-clamp times were 217 and 173 min, respectively.
[FIGURE 1 OMITTED]
The patient was extubated the next morning. Intensive care unit stay was 3 days. No cerebral, respiratory or renal complications occurred. The remaining postoperative stay was also uneventful. In postoperative period, because the clinical findings and preoperative CT were highly suggestive of a coarctation of the thoracic aorta, 3-dimensional and multislice CT was made at the thoracal region. This confirmed the presence of the thoracal coarctation, which revealed a severe coarctation of the aorta, just distal to the take-off of the left subclavian artery (Fig. 2, Video 1. See corresponding video/movie images at www.anakarder.com). The patient was discharged on the 15th postoperative day with anti-hypertensioe medications.
A month after the repair of the aneurysm, the patient underwent elective correction of the aortic coarctation. A left posterolateral thoracotomy thoracotomy /tho·ra·cot·o·my/ (-kot´ah-me) pleurotomy; incision of the chest wall.
Incision into the chest wall. Also called pleurotomy. was carried out at the fourth intercostal space, and we observed marked dilatation of the descending aorta. Cross-clamps were then placed proximally and distally to the coarctation. Due to the fact, that in descending aorta perfusion pressure was measured 60 mmHg, we did not need atrio-femoral shunt for spinal protection. The narrow isthmic segment was entirely resected and the patchplasty was performed between the distal aortic arch and the thoracic aorta with piece Dacron graft with a continuous 5/0 prolene suture.
[FIGURE 2 OMITTED]
The patient was discharged on the 7th postoperative day. On routine follow-up, the patient was in excellent condition. He returned to full-time work. On the 2nd month of follow-up, he was free of complications and two-dimensional echocardiography revealed normal heart contractility, good function of the aortic valvular prosthesis prosthesis (prŏs`thĭsĭs): see artificial limb.
Artificial substitute for a missing part of the body, usually an arm or leg. , a regular ascending aorta, and no evidence of aneurysm.
Vascular complications and arterial hypertension are major risk factors in the evolution of disease connected with coarctation of the aorta. The miscellaneous studies pointed out that aortic rupture was the cause of death in 19% to 23% of patients with coarctation of the aorta; in 75% of the instances, rupture take place in the ascending aorta (2).
In patients with ascending aortic aneurysm together with aortic coarctation, initially aortic coarctation must be repaired in one or two-stage procedure, in order to lessen proximal hypertension, decrease the chances of progressive dissection or rupture, and enable safe perfusion during correction of the aortic aneurysm (3). Surgical repair may be performed through two different incisions by thoracotomy and sternotomy in cases treated with surgery in one stage (4) or coarctation treatment may be carried out with extra-anatomical bypass following ascending aortic aneurysm repair by sternotomy only in one stage (1). In two-stage surgery, first coarctation is repaired by thoracotomy and then ascending aortic aneurysm is repaired at a later stage (2).
In cases having aortic coarctation and aortic dissection together, ascending aortic dissection is repaired and coarctation is repaired by extra-anatomical bypass in one stage or first dissection and then coarctation is repaired in two stages (3, 5). In our case, both ascending aortic aneurysm and aortic dissection suspicion occurred besides aortic coarctation. We could not treat coarctation initially because of dissection suspicion and rupture risk resulting from ascending aortic aneurysm (almost 7 cm). For this reason, ascending aortic pathology was corrected initially by sternotomy urgently.
We thought that it would not be appropriate to perform extra-anatomical bypass following aortic pathology repair in one stage and coarctation repair by thoracotomy carrying out a second incision in the same step. Because, in one-session surgery, to reach coarctated segment is difficult due to collateral circulation in case to which only sternotomy is performed. Besides, bleedings related to wide and profuse collaterals prevent reaching surgical area (2). Moreover, in the same step for coarctation treatment, surgical operation and anesthesia period increases through a second thoracotomy, infection tendency and thus surgical risk increases. That is, no attempt was performed to correct the aneurysm of the ascending aorta and the coarctation on the same occasion, by means of a compounded approach, because we considered it would extremely increase the operative time and risk, a view indicated by others in a similar situation (7). However, extra-anatomical procedures, frequently can be used for the interrupted aortic arch Interrupted aortic arch is a very rare heart defect in which the aorta is not completely developed. There is a gap between the ascending and descending thoracic aorta. Almost all patients also have other cardiac anomalies. , recoarctation and in combined procedures such as with valve and coronary artery surgery (8). For this reason, we did not prefer extra-anatomical bypass procedure that we thought to be a time-consuming and palliative procedure.
The aim of repair of cases with aortic coarctation is to allow proximal blood flow to pass distally without obstruction. This can be achieved by either widening the narrowed region or by creating an alternate path for blood flow. Surgical or endovascular techniques can be used as an alternative treatment. End-to-end anastomosis anastomosis /anas·to·mo·sis/ (ah-nas?tah-mo´sis) pl. anastomo´ses [Gr.]
1. communication between vessels by collateral channels.
2. , prosthetic interposition in·ter·pose
v. in·ter·posed, in·ter·pos·ing, in·ter·pos·es
a. To insert or introduce between parts.
b. To place (oneself) between others or things.
2. tube grafts, subclavian subclavian /sub·cla·vi·an/ (sub-kla´ve-an) below the clavicle.
Located beneath the collarbone (clavicle). flap repair, and extra-anatomical corrections (9) can be preferred for surgical treatment. We preferred to perform patchplasty to this patient of old age. In addition to the surgical procedures, there are procedures other than surgical treatment. Balloon angioplasty, endovascular repair and hybrid procedures (10) can be used as alternative treatments. Developments in endovascular technology over the past decade may potentially reduce the morbidity from open surgical repair. Endovascular devices are deployed through peripheral arteries and fluoroscopy fluoroscopy /flu·o·ros·co·py/ (fldbobr-ros´kah-pe) examination by means of the fluoroscope.
Examination by means of a fluoroscope. Also called radioscopy. is used to confirm accurate placement. Complex anatomical variations may require endovascular devices to be deployed directly into the aorta. Both surgeon and interventional radiologist must work closely to ensure accurate placement (9). However, such procedures were not preferred for our patient because of high cost and lack of endovascular procedures in our region. Generally, surgery still has an important role in the management of the adult patient with coarctation despite the recent advances of endovascular technology. Clinical trials for these patients are difficult to carry out because of the small patient number and the variety of complicating factors. The multidisciplinary team can optimize the management of these patients and combined procedures may further improve results.
The topic of how to replace the aortic valve in the presence of coarctation was not difficult to solve, because the valve was grossly abnormal: it was therefore excised and replaced with a mechanical prosthesis. Such surgical procedures as, classical and modified Bentall applications, separated surgical treatment, David and Ross procedures can be applied in cases of ascending aortic aneurysm and root replacement could be applied. We performed a Bentall replacement of the ascending aorta and aortic valve with a composite prosthesis as described by Yakut et al. (6), because the aortic root was large, the sinuses of Valsalva were enlarged, and the coronary ostia were displaced in our patient. The flanged composite graft offers excellent long-term results, with very low prevalence of prosthetic-related complications. Because the new created sinuses and the flange are especially helpful to continue physiologic function of the aortic root (6), we preferred Bentall procedure with flanged technique.
Selecting the place of arterial cannulation under these circumstances, to insure sufficient blood flow to both the upper and inferior body parts, was a matter of concern. We decided that femoral cannulation alone would not ensure adequate cerebral perfusion. We cannulated can·nu·late also can·u·late
tr.v. can·nu·lat·ed, can·nu·lat·ing, can·nu·lates
To insert a cannula into (a bodily cavity, duct, or vessel), as for the drainage of fluid or the administration of medication.
adj. the femoral and the right axillary arteries separately, in order to perfuse per·fuse
1. To pour or diffuse a liquid over or through something.
2. To force blood or other fluid to flow from the artery through the vascular bed of a tissue or to flow through the lumen of a hollow structure. cerebral and spinal regions simultaneously due to coarctation. In additional, the adequacy of the perfusion of the lower body was evaluated by continuous monitoring of urine output, which was satisfactory throughout the perfusion. Postoperatively, the patient showed evidence neither of impaired renal function nor of ischemic Ischemic
An inadequate supply of blood to a part of the body, caused by partial or total blockage of an artery.
Mentioned in: Antiangiogenic Therapy, Subarachnoid Hemorrhage, Ventricular Fibrillation
ischemic injury to the spinal chord. We presume that the satisfactory perfusion of the aorta distal to the coarctation was the result of a well-developed collateral circulation and because of axillary and femoral perfusion during procedure.
Generally, initially distal pathology related to aortic coarctation should be corrected to eliminate cardiac load in cases of aortic coarctation together with ascending aortic aneurysm. However, as in our case, because of the suspicion of dissection and rupture risk due to a very large ascending aorta, first ascending aortic aneurysm with proximally lesion was operated to treat life-threatening pathology that was thought to be urgent. A second surgical operation was not carried out in the same incision in order not to increase anesthesia period, to decrease surgical risk and thus to eliminate malperfusion risk, and coarctation treatment was left to a later period electively. Extra-anatomical bypass was not performed in the same step considering the correction of coarctation with patchplasty would be appropriate and curative, without facing any clinical problems. Besides, although antegrade perfusion with axillary cannulation may be enough in the presence of a well-developed collateral circulation, more appropriate perfusion to the upper and lower parts of the body is presumably pre·sum·a·ble
That can be presumed or taken for granted; reasonable as a supposition: presumable causes of the disaster. best accomplished by separate antegrade and retrograde cannulation.
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(2.) Cagli K, Uncu H, Cagli KU, Altintas G, Emir M, Sener E, et al. Aort koarktasyonu ve asendan aort anevrizmasi olan hastaya iki asamali cerrahi yaklasim: Olgu sunumu. Anadolu Kardiyol Derg 2002; 2:169-71.
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(8.) Bartoccioni S, Giombolini C, Fiaschini P, Martinelli G, Fedeli C, Di Lazzaro D, et al. Aortic coarctation, aortic valvular stenosis, and coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. : combined one-stage surgical therapy operation. J Card Surg 1995;10: 594-6.
(9.) Ramnarine I. Role of surgery in the management of the adult patient with coarctation of the aorta. Postgrad Med J 2005; 81: 243-7.
(10.) Carrel Car·rel , Alexis 1873-1944.
French-born American surgeon and biologist. He won a 1912 Nobel Prize for his work on vascular ligature and grafting of blood vessels and organs. TP, Berdat PA, Baumgartner I, Dinkel HP, Schmidli J. Combined surgical and endovascular approach to treat a complex aortic coarctation without extracorporeal circulation. Ann Thorac Surg 2004; 78: 1462-5.
Bilgehan Erkut, Cevdet Ugur Kocogullari, Ahmet Ozyazicioglu, Hikmet Kocak
Department of Cardiovascular Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey
Address for Correspondence/Yazisma Adresi: Cevdet Ugur Kocogullan, Assist Prof, MD, Dervispasa Mh. Dr. Mahmut Hazar Cd. Buse Apt. No: 43 A Blok B B Giris D: 4 Afyon, Turkey Phone: +90 542 235 56 03 E-mail: firstname.lastname@example.org