Asian Cardiovasc Thorac Ann 2007;15:e41-e42
© 2007 Asia Publishing EXchange Ltd
Strategy for Adult Aortic Coarctation Complicated by Coronary Artery Disease
Yasuaki Fujisawa, MD,
Kiyofumi Morishita, MD,
Johji Fukada, MD,
Yoshikazu Hachiro, MD,
Tatsuya Saito, MD,
Tomio Abe, MD
Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan
For reprint information contact: Yasuaki Fujisawa, MD Tel: 81 11 611 2111 Ext 3312 Fax: 81 11 613 7318 Email: fuji{at}sapmed.ac.jp, Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo 060-8543, Japan.
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ABSTRACT
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Aortic coarctation in adults is sometimes associated with a fragile aortic wall and may be complicated by coronary artery disease and ascending aortic dilation. Successful management of aortic coarctation in a 45-year-old man with coronary artery disease is described. Tube graft replacement was carried out without cross clamping, under circulatory arrest with axillary artery and graft inflow.
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INTRODUCTION
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There is sometimes a fragile aortic wall in adults with coarctation of the aorta, and the condition may be complicated by progressive coronary artery disease and ascending aortic dilation. Therefore, a safe surgical procedure must be employed to avoid perioperative complications and allow future intervention.
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CASE REPORT
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A 45-year-old hypertensive man went to a local hospital after sudden onset of severe chest pain. An electrocardiogram indicated acute myocardial infarction. Coronary angiography was undertaken immediately. Initial attempts using the right femoral approach were unsuccessful because of severe stenosis of the descending aorta. Therefore, the right radial artery was used for access. The angiogram showed extremely severe stenosis of up to 99% in the right coronary artery. The left anterior descending artery and the left circumflex artery were also stenosed by up to 50%. Percutaneous coronary angioplasty and stent placement was performed in the right coronary artery. An aortogram of the descending aorta revealed a postductal type coarctation of the aorta. The patient was discharged on medical therapy for coronary disease and hypertension.
Six months later, intermittent claudication had become gradually more marked. The patient was referred to our hospital for treatment of aortic coarctation. On admission, the pressure gradient between the arms and legs was 49 mm Hg. An echocardiogram showed normal contraction of the left ventricle and a tricuspid aortic valve with no regurgitation. The ascending aorta was moderately dilated. Computed tomography demonstrated coarctation of the proximal descending aorta and dilation of the descending aorta (Figure 1
), with profuse collateral vessels. Graft replacement of the descending aorta was decided. With the patient in the supine position, the right axillary artery was exposed and a 10 mm tube graft was anastomosed to it. The patient was placed in the left thoracotomy position with the lower body twisted for femoral cannulation. The descending aorta was exposed through the 4th intercostal space. The axillary tube graft was connected to the arterial cannula, and cardiopulmonary bypass (CPB) was instituted via this arterial cannula and a double-staged venous cannula inserted through the right femoral vein. Cooling was started and another arterial cannula was inserted through the right femoral artery to perfuse the lower body. After initiating ventricular fibrillation, a venting tube was inserted into the left ventricle through the left upper pulmonary vein. At 24°C, CPB was discontinued. The descending aorta was opened, and the segments with coarctation and dilatation were resected. The diseased aorta was very fragile and its dilated wall was very thin. The distal descending aorta was cross clamped, and low-flow perfusion was started from the femoral artery to provide flow to the spinal cord and lower body. Proximal anastomosis of a 22 mm tube graft was performed. After clamping this graft, perfusion of the upper body and rewarming was started via the axillary artery cannula. After completing the distal anastomosis, CPB was recommenced uneventfully. The circulatory arrest time was 15 min, and the CPB time was 158 min. The postoperative course was good, and the pressure gradient between the arms and legs disappeared.
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Figure 1. Three-dimensional computed tomography showing well-developed intercostal arteries and the internal thoracic artery, the diameter of the ascending aorta reached 40 mm.
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DISCUSSION
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Postoperative aneurysm formation and re-coarctation may develop from an increase in wall tension caused by the difference in caliber between the aorta and the vascular prosthesis in the case of extra-anatomic bypass grafting, or at the suture site in the case of patch plasty.1,2 Thus, we consider graft replacement to be the best strategy for coarctation in adults.3 As the wall of the aortic arch proximal to the coarctation and the dilated descending aorta are fragile, cross clamping the aorta carries the risk of rupture or dissection; therefore, we think it is best to use circulatory arrest. Kang and colleagues2 also recommended graft replacement without clamping, under circulatory arrest. Moreover, the complications of stroke, spinal cord ischemia, and recurrent laryngeal nerve injury due to clamping of the aortic arch are substantially avoided by this method.4
A high percentage of adults with coarctation of the aorta develop coronary artery disease.1,5,6 Our patient suffered myocardial infarction at a relatively young age, and considering the multiple stenoses of his coronary arteries, he will probably need further treatment, such as coronary bypass, in the future. Ascending aortic aneurysm is a significant complication in adults with coarctation of the aorta.7 The ascending aorta in our patient was moderately dilated with the potential to dilate further according to Laplace’s law. Previously, we have performed coarctation repair by a modified central cannulation technique, inserting an arterial cannula into the ascending aorta and inserting a venous cannula into the right atrium through the femoral vein.3 However, in this case, we had to plan a surgical strategy that took into account future treatment for coronary artery or ascending aortic disease, which may have to be performed through a median sternotomy. If the initial repair had been carried out by the central cannulation technique, adhesions in the anterior mediastinal space could be troublesome. Therefore, we decided to repair the coarctation under CPB with axillary artery inflow via a side graft and right atrial venous outflow through the right femoral vein. It has been reported that axillary/subclavian plus graft inflow reduces the incidence of stroke, and it has been proved useful for complex cardiovascular operations that necessitate circulatory arrest.8 This technique is suitable for coarctation repair in patients with the possibility of further progression of aortic and/or coronary artery disease.
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REFERENCES
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- Svensson LG, Blackstone EH, Rajeswaran J, Sabik JF 3rd, Lytle BW, Gonzalez-Stawinski G, et al. Does the arterial cannulation site for circulatory arrest influence stroke risk? Ann Thorac Surg 2004;78:1274–84.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
