Single-Stage Repair of Thoracic Aortic Aneurysm through a Median Sternotomy in a Patient with Pseudocoarctation of the Aorta and Severe Aortic Valve Stenosis

Abstract

Pseudocoarctation of the aorta is a rare anomaly and considered a benign condition. Pseudocoarctation of the aorta has been associated with aneurysm formation in the thoracic aorta, which may cause sudden rupture or dissection. Thus, the presence of an aneurysm in combination with pseudocoarctation of the aorta is thought to be an indication for surgery. We present a case of pseudocoarctation of the aorta associated with thoracic aortic aneurysm and severe aortic valve stenosis with a bicuspid aortic valve. In our case, single-stage repair was performed through a median sternotomy using our "pleural-window approach." Keywords: coarctation, aneurysm, aortic valve elevation of the brain natriuretic peptide (1577 pg/ml). A chest X-ray showed pulmonary congestion, cardiac enlargement and widening of the superior mediastinum. The results of transthoracic echocardiography showed an ejection fraction of 30%, a peak gradient across the aortic valve of 93 mmHg and an effective orifice area of 0.55 cm 2 . Enhanced computed tomography (CT) performed subsequently revealed kinking in the distal aortic arch with stenosis (Fig. 1A), poststenotic dilatation of the descending aorta (45 mm), a left subclavian artery aneurysm (30 mm) and no significant collateral vessels (Fig. 1B). There was no systolic pressure gradient between the upper and lower extremities. As descending aorta tended to expand, we thought that the aneurysm was needed for resection. After treatment of CHF, we performed single-stage surgery through a median sternotomy (Fig. 1C). Total cardiopulmonary bypass was initiated by cannulating the ascending aorta. The common femoral artery was isolated and cannulated with an 18 Fr cannula. After the ascending aorta was clamped and cardiac arrest was obtained, the ascending aorta was opened. We found a bicuspid aortic valve and performed aortic valve replacement (AVR) with a 21-mm bovine pericardial bioprosthetic aortic valve. A wide incision of the left pleura was made from the aortic arch to the diaphragm. The left lung was mobilized to the right side and the narrowed segment and descending aortic aneurysm were clearly visible when the heart with the pleura and pericardium were retracted. After the patient was cooled to 28°C and the descending aorta was clamped, antegrade cerebral perfusion and femoral artery perfusion were initiated (Fig. 2A). The aneurysm wall was thinned and diameter of the narrowed segment was 9 mm (Fig. 2B). The distal aortic anastomosis was completed with a fourbranched woven Dacron graft. After antegrade flow to the lower body was established through a side branch of the graft, the ascending aorta, brachiocephalic and carotid arteries were anastomosed. The third graft limb was anastomosed to the left axillal artery through the pleural cavity and the left subclavian artery aneurysm was resected and

A Pseudocoarctation of the Aorta With a Left Subclavian Artery Aneurysm, A Case Report and A Review of the Literature

“…In cases where open surgery was reported for PCoA, a friable and thin tissue was observed and histologically demonstrated, a condition that was also present in our patient. 23,27 Therefore, the potential for growth, rupture, or dissection should be considered in the presence of any kind of aneurysm related to PCoA.…”

Bicuspid aortic valve with critical coarctation of the aorta: single- or two-stage operation?

“…In our center, we prefer using a bypass graft to avoid the neurological complications such as laryngeal nerve palsy or spinal cord ischemia, since the lesion is often long and complex in patients of BAV with CoA. However, the new single-stage procedure reported for such patients provides us another choice (8,12,19,21). During this operation, routine cardiopulmonary bypass is initiated, and the extra-anatomic bypass from the ascending aorta to the descending aorta is ideally anastomosed first to supply the descending aorta before cardioplegia is delivered.…”

“…Surgeons may prefer a two-stage procedure because it may be easier to expose the narrowed segment and descending aorta. However, the single-stage procedure through a median sternotomy can also provide a clear view when the heart and pericardium are retracted through a left pleural incision (5,8,12,19,21). Meanwhile, endovascular therapy (Balloon angioplasty or Stent implantation) is also a good choice for CoA patients.…”

“…The single-stage procedure commonly involved an extraanatomic bypass from the ascending aorta to the distal aorta of the narrow segment and other surgical repairs for cardiac defects (mainly aortic valve dysfunction) through a median sternotomy (8,12,19,21). In most cases, the extraanatomic bypass procedure was performed as soon as the cardiopulmonary bypass was initiated by cannulating the ascending aorta.…”

“…Because the simultaneous presence of a BAV and CoA involves both aortic valve disorders and aortic wall abnormalities, as well as other complex lesions in some patients, surgical treatment is conventionally performed in two stages: the critical CoA is managed first, and the abnormality of the aortic valve is addressed later. Recently, some cases who underwent single-stage procedure have been reported (12,(19)(20)(21)(22). However, we recently performed…”