Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach

Abstract

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.

Single-Stage Repair of a Critical Aortic Coarctation, a Bicuspid Aortic Stenosis and an Ascending Aortic Aneurysm

“…The complex pathology of AC with aortic root aneurysm, presenting in adulthood, poses a tactical challenge [3]. The single-stage procedure, with combination of an extra-anatomic aortic bypass and concomitant cardiovascular disorders repair via median sternotomy, might be a useful and a safe alternative, which can be performed efficiently with low morbidity and mortality [1] …”

“…Various techniques have been proposed to decrease those potential complications ( [5]- [7] such as the use of deep hypothermic circulatory arrest [5] or the extra-anatomic ascending-to-descending aortic bypass [1]- [4] [8] [11]. Ananiadou reported excellent results with no surgical mortality or graft-related complications [3]. Thanks to lateral partial aortic clamp that allows continuation of blood flow to the posterior wall of the aorta, paraplegia is rarely described with the extra-anatomic bypass [2] [4] [8].…”

“…At the admission, the patient had no fever and the lab tests showed normal leukocytes (9875/mm 3 ) and the C reactive protein was at 7 mg/L. No germ had been isolated on blood culture test.…”

“…The best surgical approach is still uncertain since there are no guidelines about this topic [1]. However, it seems that the single-stage approach for simultaneous repair of cardiac lesions and ascending-to-descending aortic extra-anatomic bypass through median sternotomy is a safe technique, which avoids the complications of the anatomic repair and the double-stage surgery [2] [3]. The aim of this observation is to underline the excellent result of the single-stage surgery with a long term patency of the extraanatomic graft.…”

Endovascular repair of de novo post-stenotic aortic coarctation aneurysms with complex collateral supply: two cases with long and medium term follow-up

“…Thoracic Endovascular Aneurysm Repair (TEVAR) is the accepted first-line treatment for post-surgical aneurysms, given the mortality rate of 14% for repeat open surgery (Ince et al 2003). Successful open surgery for de-novo TAC associated aneurysms is limited to case reports (Ruys et al 2014;Ananiadou et al 2012;Careaga-Reyna et al 2009). Stent-grafts in combination with other endovascular techniques offer a flexible alternative to cope with anatomic complexity (Kutty et al 2008).…”