Asian Cardiovasc Thorac Ann 2003;11:357-358
© 2003 Asia Publishing EXchange Ltd
Ascending Aorta-Abdominal Aorta Bypass for Takayasu’s Arteritis
Hyuk Ahn, MD,
Ho Young Hwang, MD
Department of Thoracic & Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
For reprint information contact: Hyuk Ahn, MD Tel: 82 2 760 3349 Fax: 82 2 764 3664 email: ahnhyuk{at}snu.ac.kr Department of Thoracic & Cardiovascular Surgery, Seoul National University Hospital, 28 Yongon-dong, Chongro-gu, Seoul 110-774, Korea.
 |
ABSTRACT
|
|---|
Three patients with type III Takayasu’s arteritis were referred to us because of the upper extremity hypertension and vascular claudication of the lower extremities. They underwent extra-anatomic ascending aorta-abdominal aorta bypass with vascular graft under a median sternotomy and a splitted midline laparotomy incision without cardiopulmonary bypass. The postoperative course was uneventful. Upper extremity hypertension and vascular claudication were completely resolved.
|
INTRODUCTION
|
|---|
Takayasu’s arteritis is a nonspecific inflammatory disorder involving the aorta, its branches, and the pulmonary artery. Surgery is required for its steno-occlusive lesion.
|
CASE REPORTS
|
|---|
The first case involved a 57-year-old woman who was admitted with a diagnosis of Takayasu’s arteritis. Her blood pressure was 190/110 mm Hg in the right arm, 100/70 mm Hg in the left and 100/80 mm Hg in the lower extremities. Transthoracic echocardiography demonstrated left ventricular hypertrophy and calculated left ventricular mass index (LVMI) was 216.1g•m-2. Computed tomographic (CT) angiography revealed diffuse narrowing of the descending thoracic to abdominal aorta (Figure 1
), the left common carotid artery and the left subclavian artery. The operative approach was through a median sternotomy and a splitted midline laparotomy incision. A 12 mm Vascutek vascular graft (Sulzer Vascutek Ltd., Scotland) was anastomosed end-to-side to the ascending aorta with a side-biting clamp. The graft was then tunneled through the right pleural cavity, the diaphragm, anterior to the liver, between the stomach and the pancreas, and brought into the retroperitoneal space. The graft was anastomosed end-to-side to the infrarenal abdominal aorta under cross-clamps at proximal and distal part of the anastomosis site and covered with omentum and posterior parietal peritoneum. The pressure difference was completely resolved. Postoperative CT angiography demonstrated successful bypass graft (Figure 2). Blood pressure was 120/80 mm Hg in the right arm, 100/70 mm Hg in the left and 150/90 mm Hg in the lower extremities on the 10th postoperative day. The patient was discharged on the 11th postoperative day without complication.
View larger version (129K):
[in this window]
[in a new window]
|
Figure 1. Preoperative Computed tomographic (CT) angiography. CT with 3D reconstruction shows diffuse calcification and narrowing of the descending thoracic and abdominal aorta.
|
|
View larger version (115K):
[in this window]
[in a new window]
|
Figure 2. Postoperative CT angiography. 3D reconstructed image demonstrates patent ascending aorta-infrarenal abdominal aorta bypass graft.
|
|
A second case involved a 46-year-old woman who was admitted with a vascular claudication and headache. She was diagnosed as Takayasu’s arteritis. On physical examination, blood pressure was 200/80 mm Hg in the left arm, 150/80 mm Hg in the right and 120/80 mm Hg in both legs. The LVMI was 165.8g•m-2. The pressure difference due to diffuse narrowing of the desceding thoracic aorta was relieved by the same manner with a 12 mm Hemashield vascular graft (Meadox Medicals, Inc., Oakland, USA) (Figure 3). Postoperative blood pressure was 160/90 mm Hg in the right arm, 140/100 mm Hg in the left and 150/90 mm Hg in both legs. She was discharged on the 10th postoperative day.
View larger version (93K):
[in this window]
[in a new window]
|
Figure 3. Preoperative and postoperative images. Preoperative aortography shows diffuse stenosis of the descending thoracic aorta. Postoperative CT with 3D reconstruction demonstrates patent extra-anatomic bypass graft.
|
|
The third case involved a 23-year-old man who was diagnosed as Takayasu’s arteritis that involved the right coronary artery, as well as the subclavian artery and descending thoracic aorta. The peak pressure gradient between upper and lower extremities was 130 mm Hg. Ascending aorta-abdominal aorta bypass graft was done utilizing an 18 mm woven Dacron graft. He was discharged on the 13th postoperative day without complication.
|
DISCUSSION
|
|---|
Type III Takayasu’s arteritis is characterized by a combination of occlusive lesions of the main branches of the aortic arch (type I) and narrowing of the thoraco-abdominal aorta and its branches (type II).1,2
Standard aortic surgery usually comprises resection and anastomosis or replacement of a diseased segment. Even though very extensive aortic replacement is possible with the advancement of modern cardiovascular surgery, complex vascular problems may call for extra-anatomic bypass grafts.3 Blasidell and associates4 described the descending thoracic aorta-bilateral femoral arteries bypass for a patient with an infected abdominal aortic prosthesis in 1961. The concept of utilizing the ascending aorta for proximal anastomosis for such bypass grafts was described by Schumacker and associates5 in 1968 for a patient with mycotic aneurysm following repair of coarctation of the thoracic aorta.
In the cases reported here, surgery was required mainly due to upper extremity hypertension caused by the descending thoracic and abdominal aortic stenosis. Extra-anatomic bypass graft was the treatment of choice because the lesions were too extensive for the standard treatment. Operation with a shorter incision was possible through a median sternotomy and a splitted midline laparotomy. Great care was taken to ensure that the distal anastomotic site was retroperitoneal and well covered with posterior parietal peritoneum and to wrap the distal part of the graft with omentum. It may help to prevent fatal complications such as aorto-intestinal fistula and pseudoaneurysmal change of the anastomosis site.6 In patients with type II and III Takayasu’s arteritis, extra-anatomic ascending aorta-abdominal aorta bypass can be a treatment of choice for relief of upper extremity hypertension and associated symptoms.
|
REFERENCES
|
|---|
- Inada K. Atypical coarctation of the aorta with a special reference to its genesis. Angiology
1965;16:608–15.
- Nakao K, Ikeda M, Kimata S, Niitani H, Niyahara M. Takayasu’s arteritis: clinical report of eighty-four cases and immunological studies of seven cases. Circulation
1967;35:1141–55.[Abstract/Free Full Text]
- Heinemann MK, Ziemer G, Wahlers T, Kohler A, Borst HG. Extra-anatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur J Cardiothorac Surg
1997;11:169–75.[Abstract]
- Blaisdell FW, DeMattei GA, Gauder PJ. Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation graft. Am J Surg
1961;102:583–5.
- Shumacker HB Jr, King H, Nahrwold DL, Waldhausen JA. Coarctation of the aorta. Curr Probl Surg
1968;Feb:1–62.
- Gelfand ET, Callaghan JC, Sterns LP. Extended aortic bypass. J Thorac Cardiovasc Surg
1980;79:381–7.[Abstract]
TOP
ABSTRACT
INTRODUCTION
