Successful outcome of complications of excision of aortic coarctation.

Abstract

Khan, R. M. A. and Bloor, K. (1975). Thorax, 30,[344][345][346][347]. Successful outcome of complications of excision of aortic coarctation. A case is described of a patient who made a complete recovery following unusually serious complications of excision of aortic coarctation. The thoracic aorta was reconstructed successfully using an aortic graft along a course which appears to be short and direct.Crafoord and Nylin (1945) and Gross and Hufnagel (1945) first described the surgical treatment of coarctation of the aorta. The operative mortality of about 5% appears to be fairly constant in most series (Claggett, Kirklin, and Ellis, 1955;Schuster and Gross, 1962;Karnell, 1968). About one-third of the fatal complications seem to be due directly to damage to easily traumatized vessels or to anastomotic disruptions. The case of a 19-year-old man who had his left subclavian artery, arch of the aorta, and lower thoracic aorta ligated following such complications is described. The continuity was restored successfully by using an aortic graft between the ascending and lower thoracic aorta. For difficult, inaccessible or recurrent aortic coarctations, a course for the graft is described, which appears to be short and direct. Since there was no improvement in the arterial pulsations in the lower limbs, an arch aortogram was carried out. This showed that the proximal anastomosis was about 8 mm wide. A further exploratory thoracotomy was performed one month after the first thoracotomy. There were a few blood clots which were removed. The left subclavian artery, the arch of the aorta, and the proximal end of the graft were mobilized. The aorta was cross-clamped and the proximal end of the graft was detached. While the distal anastomosis was being examined, bleeding started from near the aortic cross-clamp. At this stage the left subclavian artery came off the aortic arch and had to be clamped and ligated. The aortic crossclamp was replaced more proximally close to the left common carotid artery. During this process the phrenic and vagus nerves were divided. By this time considerable blood loss had taken place, which resulted in cardiac arrest. The blood replacement was speeded up, cardiac massage begun, and an intracardiac injection of adrenaline hydrochloride given. This resulted in ventricular fibrillation, which responded well to a single direct current shock.In view of the very friable vascular tissue and the fact that not enough of the aorta was available proximally for a further anastomosis, the situation was accepted. The arch of the aorta between the left subclavian and common carotid arteries was transfixed and ligated and so was the lower thoracic aorta. Following a rather protracted convalescence the patient was discharged home a month after the last operation.He was readmitted three months later for further investigations and assessment. His only 344 on 10 May 2018 by guest. Protected by copyright.