Repair of Aortic Coarctation in an Adult by Direct Aortoplasty
Nicholas Charokopos, PhD,
Panagiotis Artemiou, MD,
Polychronis Antonitsis, PhD,
Efthymia Rouska, MD,
Ioannis Stinios, MD
First Department of Thoracic and Cardiovascular Surgery Aristotle University of Thessaloniki, Thessaloniki, Greece
Nicholas Charokopos, PhD, Tel: +30 6977014054, Fax: +30 2310340034, Email: charokoposnick{at}hotmail.com, 22 Grigoriou E’ St., Panorama, 552 36 Thessaloniki, Greece.
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ABSTRACT
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Various techniques have been proposed for surgical correction of aortic coarctation in adults. We describe direct aortoplasty repair in a 28-year-old woman with native coarctation. Four-year follow-up with magnetic resonance angiography confirmed a good result. This is a safe and effective technique that provides enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.
Key Words: Aortic Coarctation • Thoracic Surgical Procedures
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INTRODUCTION
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Coarctation in adults may occur in previously unrepaired patients or those who have undergone prior surgical correction. In native coarctation, an abnormality of the media creates a posterior shelf, opposite the ligamentum arteriosum, which may extend circumferentially. Uncorrected coarctation is associated with chronic hypertension that can result in congestive heart failure, myocardial infarction, aortic rupture, stroke, or infective endocarditis.1 Various techniques have been proposed for surgical correction in adults. The choice depends on the character of the lesion as well as any other congenital anomalies of the heart and great vessels. This report describes the use of a direct aortoplasty technique for surgical repair of aortic coarctation in an adult.
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CASE REPORT
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A 28-year-old lady presented with history of poorly controlled arterial hypertension during the previous 10 years. Clinical examination revealed low arterial blood pressure in both lower limbs and a loud mid-back holosystolic murmur on auscultation. Spiral computed tomography showed severe coarctation of the aorta with dilatation of the ascending aorta, the aortic arch, bilateral internal thoracic and intercostal arteries. Echocardiography revealed left ventricular hypertrophy and mild aortic regurgitation. Surgery was performed through a left posterolateral thoracotomy at the 4th intercostal space. The coarctated segment of the aorta and the dilated left subclavian artery (LSA) were identified and carefully mobilized. Great care was taken to avoid tearing the enlarged intercostal arteries. The ligamentum arteriosum was ligated. After clamping the aorta and LSA, the anterior wall of the aorta was incised longitudinally, beginning at the LSA and extending 3 cm past the coarctation site (Figure 1
). The incision was sutured transversely with continuous 5/0 Prolene suture, resulting in widening of the aortic lumen at the level of the coarctation site, with preservation of left upper limb perfusion (Figure 2). The total aortic crossclamp time was 27 min. The postoperative course was uneventful. Control of arterial hypertension required an angiotensin-converting enzyme inhibitor. Two years after the operation, the patient experienced normal childbirth. Follow-up magnetic resonance angiography 4 years after the repair showed a normal diameter of the proximal descending thoracic aorta (Figure 3).
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Figure 1. (A) Schematic view of the longitudinal incision beginning from left subclavian artery and extending 3 cm past the coarctation site. (B) Operative view of the dissected vessels. The ligamentum arteriosum is ligated. White arrow indicates coarctation site. LSA = left subclavian artery.
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Figure 2. (A) The longitudinal incision is sutured transversely (schematic view). (B) Operative view after coarctation repair.
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Figure 3. Magnetic resonance angiography 4 years after repair confirmed a normal diameter of the proximal descending thoracic aorta.
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DISCUSSION
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Surgery is considered the treatment of choice for aortic coarctation in children and adults.2 The aim is to improve distal perfusion and control arterial hypertension. Coarctation repair in adults presents certain technical difficulties, such as the thickness of the aortic wall, aortic arch mobilization, the presence of calcification, and large collateral arteries with possible aneurysmal dilatation.3 The classic technique used most commonly in adults is resection and end-to-end anastomosis. It provides the advantage of avoiding foreign material, other than sutures.4 When adequate resection of the coarctation segment results in a discrepancy that precludes end-to-end anastomosis, interposition of a Dacron graft can establish continuity of the vessel.5 A Dacron tube graft can be used to bypass the coarctation, creating proximal anastomosis to the LSA or the aorta. Patch aortoplasty repair should be avoided in adults as it is associated with a high incidence of aneurysm formation. During the last decade, primary angioplasty or stenting of native adult aortic coarctation has evolved with promising results in terms of morbidity and mortality, although higher recurrence and re-intervention rates have been reported.6
The technique of direct aortoplasty described here provides a simple and safe method of repair, which avoids the use of prosthetic material. It creates minimal tension on the suture line, and requires minimal dissection and vessel manipulation in an area with enlarged collateral circulation. The internal thoracic artery remains intact and can be used for coronary surgery if ischemic heart disease develops. In coarctation surgery, restenosis and aneurysm formation are concerns. Recoarctation is less frequent in adults as the aorta has reached adult proportions.1 It can be attributed to inadequate growth of the anastomosis, active fibrosis and narrowing at the anastomotic site, thrombosis at the suture line, especially when a prosthetic graft is used, or retention of ductal tissue. The direct aortoplasty technique is characterized by avoidance of foreign graft material and the potential for coarctation membrane resection. Aneurysm formation ceases to be a significant problem in adults after surgery, due to the development of tough fibrous tissue around the site of repair. Patch angioplasty and advanced age at repair are considered to be the main risk factors contributing to aneurysm formation.7 On the other hand, angioplasty and stenting create structural defects of the intima and media layers, which can lead to aneurysmal dilatation in the long term.
Direct aortoplasty, whenever anatomically feasible, provides a safe and effective technique of adult coarctation repair that creates enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.
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REFERENCES
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Asian Cardiovasc Thorac Ann 2009;
17:516-518
© 2009 by SAGE Publications
DOI: 10.1177/0218492309348632
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ABSTRACT
INTRODUCTION
