Ann Vasc Dis Vol. 6, No. 3; 2013; pp 670–673 ©2013 Annals of Vascular Diseases
Online August 30, 2013 doi:10.3400/avd.cr.13-00039
Case Report
Successful Ascending Aorta-Abdominal Aorta Bypass Graft through the Left Thoracic Cavity in a Patient with Atypical Coarctation Shogo Obata, MD, Shogo Mukai, MD, Hironobu Morimoto, MD, Toshifumi Hiraoka, MD, Hiroaki Uchida, MD, and Yoshitaka Yamane, MD
A 67-year-old woman admitted with severe hypertension, atrial fibrillation, and dyspnea was found to have hypertension and congestive heart failure due to stenosis of the descending aorta. Atypical aortic coarctation was diagnosed. Extra-anatomical bypass was performed from the ascending aorta to the terminal abdominal aorta and the pulmonary vein was isolated. The graft was arranged to pass through the left thoracic cavity from the pericardium via a transretroperitoneal approach to the terminal abdominal aorta. Direct contact was avoided between the graft and the abdominal organs, and the pressure gradient between the ascending aorta and the abdominal aorta was decreased. Keywords: atypical coarctation, hypertensive heart failure, ascending aorta-abdominal aorta bypass
Introduction
A
typical coarctation of the aorta caused by atherosclerotic disease has a predilection for the descending thoracic or abdominal aorta. Extra-anatomical bypass surgery is typically performed in cases of hypertensive heart failure with increased afterload. We present here a case of atypical coarctation of the aorta in which ascending aorta-abdominal aorta bypass grafting passing through the left thoracic cavity was performed successfully, without complications.
Case Report A 67-year-old woman was referred to our hospital with severe hypertension and general fatigue. She had been diagnosed with hypertension at the age of 23 and Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama, Hiroshima, Japan Received: April 17, 2013; Accepted: July 31, 2013 Corresponding author: Shogo Obata, MD. Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, 2-39 Midorimachi, Fukuyama, Hiroshima 720-0804, Japan Tel: +81-84-931-1111, Fax: +81-84-925-9650 E-mail: [email protected]
670
AVD-CR 13-00039 Obata_P.indd
started taking medication from age 34. However, despite several years on a b-blocker, calcium antagonist, and angiotensin receptor blocker, her hypertension was poorly controlled, with a systolic blood pressure of >200 mmHg and mild respiratory failure, and therefore underwent a detailed examination. Chest computed tomography (CT) revealed a high-grade stenotic lesion of the descending aorta and she was consequently referred to our hospital and admitted. On examination, her height was 150 cm, weight 73 kg, and body mass index 34. Blood pressure was 169/63 mmHg in the right upper extremity, 179/63 mmHg in the left upper extremity, 106/59/63 mmHg in the right lower extremity, and 104/55 mmHg in the left lower extremity. Her pulse was irregular and revealed atrial fibrillation. Cardiac murmurs but no crepitations were audible and no remarkable neurological findings were observed. Chest X-ray revealed cardiomegaly with a cardiothoracic ratio of 60.1% and pulmonary congestion (Fig. 1). Plain thoracic CT showed calcification of the entire circumference of the descending aorta accompanied by stenosis (Fig. 2A). A pressure gradient of approximately 100 mmHg was determined by aortic catheterization (Fig. 2B). Cardiac catheterization indicated no significant
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
670
2013/09/11
15:33:42
Left Thoracic Ascending-Abdominal Aorta Bypass
(A)
(B)
Fig. 1 Preoperative thoracic X-ray shows pulmonary congestion and cardiomegaly with a cardiothoracic ratio (CTR) of 60.3%.
stenosis of the coronary arteries. An echocardiogram showed an ejection fraction of 75% and left ventricular wall motion was normal, but respiratory fluctuations of the inferior vena cava were decreased to 48%. Atypical coarctation of the aorta due to Takayasu’s arteritis was strongly suspected as she met the following diagnostic criteria: age at disease onset 10 mmHg in systolic blood pressure between the arms, and arteriogram abnormality. Descending aortic stenosis was classified as type III, and afterload reduction was considered necessary. However, direct bypass or percutaneous transluminal angioplasty for the lesion in the aortic arch and descending aorta, along with the severe stenosis and calcification present, would be a difficult as well as highrisk procedure. Therefore, we decided to conduct an extra-anatomical bypass operation. The graft used was a 14-mm J-graft. First, a 7-mm graft was used to create a branch in the 14-mm graft. The approach was via a median sternotomy extending to the umbilicus as a midline abdominal incision. The retroperitoneum was cleared, the abdominal aorta was extirpated, and the route for the abdominal aorta was created from the left thoracic cavity to the left retroperitoneum. First, an endto-side anastomosis was created to the abdominal aorta with the bifurcated graft. Next, aortic cannulas were inserted into the ascending aorta and venous cannulas were inserted into the superior and inferior vena cavae,
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00039 Obata_P.indd
671
Fig. 2 P reoperative imaging results. (A) Plain computed tomography (CT) shows calcification and stenosis of the descending aorta. (B) Angiography shows favorable results of the peripheral side of the stenotic region.
and extracorporeal circulation was initiated. Blood perfusion was also initiated from the previously anastomosed graft side branches. The pulmonary veins were ablated using a bipolar radiofrequency device (Cardioblate; Medtronic, Minneapolis, Minnesota, USA). On confirming reversion to sinus rhythm and after cross-clamping the ascending aorta, antegrade cardioplegia was induced. The graft was passed sequentially through the left retroperitoneum, the diaphragm, and the left thoracic cavity while under cardiac arrest. Then, an end-to-side anastomosis was created between the graft and the ascending aorta, avoiding the area of calcification in the ascending aorta. Finally, in the left thoracic cavity, an end-to-end anastomosis was created between the proximal and distal grafts and the branched 7-mm graft was ligated. The
671
2013/09/11
15:33:43
Obata S, et al.
(A)
(B)
Fig. 3 Postoperative imaging results. (A) Three-dimensional computed tomography (3D CT) shows a satisfactory graft and no stenosis of the abdominal vessels. (B) Thoracic X-ray. Cardiothoracic ratio (CTR) is 57%. Improvement of both cardiomegaly and pulmonary congestion is evident.
patient was started on oral steroids postoperatively, and no pressure gradient was observed between the upper and lower limbs on manometry. Hypertension could be well controlled by a b-blocker alone. Heart rate was maintained in sinus rhythm, and chest X-ray showed improvement of the cardiomegaly (Fig. 3A). Postoperative CT showed good graft patency (Fig. 3B). As the patient’s course was favorable, she was discharged in remission on postoperative day 15.
Discussion Atypical coarctation of the aorta is an arteriosclerotic disease frequently affecting the thoracic ascending and descending aorta, as well as the abdominal aorta. There is no stenosis of the branches of the aortic arch, and when the stenotic lesions are confined to the abdominal aorta, it is referred to as “midaortic syndrome”. While there are several causes of aortic coarctation, aortitis syndrome is the most common cause. The patient’s condition results in central hypertension and failure of peripheral perfusion in the region of coarctation. Cardiac failure in particular exerted a significant influence on
672
AVD-CR 13-00039 Obata_P.indd
prognosis of the present patient.1) Her uncontrollable hypertension over the long term and accompanying hypertensive cardiac failure made her a candidate for surgical treatment.1,2) Various surgical techniques can be used in adults with atypical coarctation of the aorta arising from the region of coarctation and its surroundings, including vascular prosthesis implantation, patch-angioplasty, aorto-aortic bypass, and axillo-bifemoral bypass.3-5) The reason we selected ascending aorta-abdominal aorta bypass was because, despite it requiring a median sternotomy incision to the abdomen, we were able to use a large caliber vascular graft and thus expected to ensure a reliably alleviated afterload, long-term vascular graft patency, and satisfactory perfusion of the abdominal branching vessels. In addition, as we intended to perform pulmonary vein isolation for the atrial fibrillation, it was possible to obtain a good field of view of the ascending aorta and the expansion of the heart by midline sternotomy, and it was easy and safe to establish extracorporeal circulation.6) Routes that can be selected for ascending aorta-abdominal aorta bypass are intra-abdominal, retroperitoneal (anterior pancreatic aspect and posterior pancreatic region), and
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
672
2013/09/11
15:33:44
Left Thoracic Ascending-Abdominal Aorta Bypass
beneath the rectum abdominis, but the retroperitoneal route is generally chosen because it does not allow contact between the gastrointestinal system and the vascular graft.6) However, the retroperitoneal route passes over the anterior aspect of the liver, continues through an aperture in the lesser omentum, and requires the graft to pass through the peritoneum. In addition, whether the anterior or posterior route to the pancreas is chosen, dissection around the pancreas is required, which carries a risk of postoperative pancreatitis. For this reason, the vascular graft in the present case was guided via the left thoracic cavity from the retroperitoneum to the abdominal aorta and anastomosed, making it possible to avoid exposing the graft to the intraperitoneal and peripancreatic procedures. In addition, using the route through the left thoracic cavity makes it possible to bypass the direct bifurcation of the left subclavian artery if necessary. On the other hand, a long vascular graft was required, but large-caliber vessels are usually considered to retain their patency.7) With regard to extracorporeal circulation, there were concerns that the vascular characteristics of the anastomosed region were fragile. As the patient had obvious hypertensive complications, partial aortic clamping was not used, and extracorporeal circulation under cardiac arrest was considered safer for creating a sufficiently large anastomotic opening in the central side of the ascending aorta. In addition, as it was safer and more reliable to conduct pulmonary vein isolation for the atrial fibrillation, perfusing the abdominal organs below the region of stricture was considered extremely useful before creating the anastomosis to the abdominal aorta. The patient’s postoperative course was uneventful and recovery was good. However, due to the possibility of relapse or postoperative exacerbation of aortitis, which would cause closure or stricture of the carotid bifurcations, the patient was administered oral steroids and strictly followed. Continued control of arteritis and hypertension is necessary to improve prognosis.8)
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00039 Obata_P.indd
673
Conclusion Ascending aorta-abdominal aorta bypass grafting via the left thoracic cavity may be a safe and useful procedure for patients with uncontrollable hypertension caused by atypical coarctation of the aorta.
Disclosure Statement The authors declare no conflicts of interest.
References 1) Aris A, Subirana MT, Ferrés P, et al. Repair of aortic coarctation in patients more than 50 years of age. Ann Thorac Surg 1999; 67: 1376-9. 2) Taketani T, Miyata T, Morota T, et al. Surgical treatment of atypical aortic coarctation complicating Takayasu’s arteritis—experience with 33 cases over 44 years. J Vasc Surg 2005; 41: 597-601. 3) Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000; 70: 31-7. 4) Tanaka M, Hirayama T, Yusa H, et al. A successful case of ascending aorta-abdominal aorta bypass in a patient with atypical coarctation. Jpn J Cardiovasc Surg 2007; 36: 132-6. 5) Kiji T, Kijima Y, Yamaguchi A. Axillo-bifemoral artery bypass for atypical coarctation. Jpn J Cardiovasc Surg 2000; 29: 94-7. 6) Inagaki E, Hamanaka S, Minami K, et al. Three cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu’s aortitis. Jpn J Cardiovasc Surg 2009; 38: 239-43. 7) Almeida de Oliveira S, Lisboa LA, Dallan LA, et al. Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results. Ann Thorac Surg 2003; 76: 1962-6. 8) Miyata T, Sato O, Deguchi J, et al. Anastomotic aneurysms after surgical treatment of Takayasu’s arteritis: a 40-year experience. J Vasc Surg 1998; 27: 438-45.
673
2013/09/11
15:33:44
Online August 30, 2013 doi:10.3400/avd.cr.13-00039
Case Report
Successful Ascending Aorta-Abdominal Aorta Bypass Graft through the Left Thoracic Cavity in a Patient with Atypical Coarctation Shogo Obata, MD, Shogo Mukai, MD, Hironobu Morimoto, MD, Toshifumi Hiraoka, MD, Hiroaki Uchida, MD, and Yoshitaka Yamane, MD
A 67-year-old woman admitted with severe hypertension, atrial fibrillation, and dyspnea was found to have hypertension and congestive heart failure due to stenosis of the descending aorta. Atypical aortic coarctation was diagnosed. Extra-anatomical bypass was performed from the ascending aorta to the terminal abdominal aorta and the pulmonary vein was isolated. The graft was arranged to pass through the left thoracic cavity from the pericardium via a transretroperitoneal approach to the terminal abdominal aorta. Direct contact was avoided between the graft and the abdominal organs, and the pressure gradient between the ascending aorta and the abdominal aorta was decreased. Keywords: atypical coarctation, hypertensive heart failure, ascending aorta-abdominal aorta bypass
Introduction
A
typical coarctation of the aorta caused by atherosclerotic disease has a predilection for the descending thoracic or abdominal aorta. Extra-anatomical bypass surgery is typically performed in cases of hypertensive heart failure with increased afterload. We present here a case of atypical coarctation of the aorta in which ascending aorta-abdominal aorta bypass grafting passing through the left thoracic cavity was performed successfully, without complications.
Case Report A 67-year-old woman was referred to our hospital with severe hypertension and general fatigue. She had been diagnosed with hypertension at the age of 23 and Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama, Hiroshima, Japan Received: April 17, 2013; Accepted: July 31, 2013 Corresponding author: Shogo Obata, MD. Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, 2-39 Midorimachi, Fukuyama, Hiroshima 720-0804, Japan Tel: +81-84-931-1111, Fax: +81-84-925-9650 E-mail: [email protected]
670
AVD-CR 13-00039 Obata_P.indd
started taking medication from age 34. However, despite several years on a b-blocker, calcium antagonist, and angiotensin receptor blocker, her hypertension was poorly controlled, with a systolic blood pressure of >200 mmHg and mild respiratory failure, and therefore underwent a detailed examination. Chest computed tomography (CT) revealed a high-grade stenotic lesion of the descending aorta and she was consequently referred to our hospital and admitted. On examination, her height was 150 cm, weight 73 kg, and body mass index 34. Blood pressure was 169/63 mmHg in the right upper extremity, 179/63 mmHg in the left upper extremity, 106/59/63 mmHg in the right lower extremity, and 104/55 mmHg in the left lower extremity. Her pulse was irregular and revealed atrial fibrillation. Cardiac murmurs but no crepitations were audible and no remarkable neurological findings were observed. Chest X-ray revealed cardiomegaly with a cardiothoracic ratio of 60.1% and pulmonary congestion (Fig. 1). Plain thoracic CT showed calcification of the entire circumference of the descending aorta accompanied by stenosis (Fig. 2A). A pressure gradient of approximately 100 mmHg was determined by aortic catheterization (Fig. 2B). Cardiac catheterization indicated no significant
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
670
2013/09/11
15:33:42
Left Thoracic Ascending-Abdominal Aorta Bypass
(A)
(B)
Fig. 1 Preoperative thoracic X-ray shows pulmonary congestion and cardiomegaly with a cardiothoracic ratio (CTR) of 60.3%.
stenosis of the coronary arteries. An echocardiogram showed an ejection fraction of 75% and left ventricular wall motion was normal, but respiratory fluctuations of the inferior vena cava were decreased to 48%. Atypical coarctation of the aorta due to Takayasu’s arteritis was strongly suspected as she met the following diagnostic criteria: age at disease onset 10 mmHg in systolic blood pressure between the arms, and arteriogram abnormality. Descending aortic stenosis was classified as type III, and afterload reduction was considered necessary. However, direct bypass or percutaneous transluminal angioplasty for the lesion in the aortic arch and descending aorta, along with the severe stenosis and calcification present, would be a difficult as well as highrisk procedure. Therefore, we decided to conduct an extra-anatomical bypass operation. The graft used was a 14-mm J-graft. First, a 7-mm graft was used to create a branch in the 14-mm graft. The approach was via a median sternotomy extending to the umbilicus as a midline abdominal incision. The retroperitoneum was cleared, the abdominal aorta was extirpated, and the route for the abdominal aorta was created from the left thoracic cavity to the left retroperitoneum. First, an endto-side anastomosis was created to the abdominal aorta with the bifurcated graft. Next, aortic cannulas were inserted into the ascending aorta and venous cannulas were inserted into the superior and inferior vena cavae,
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00039 Obata_P.indd
671
Fig. 2 P reoperative imaging results. (A) Plain computed tomography (CT) shows calcification and stenosis of the descending aorta. (B) Angiography shows favorable results of the peripheral side of the stenotic region.
and extracorporeal circulation was initiated. Blood perfusion was also initiated from the previously anastomosed graft side branches. The pulmonary veins were ablated using a bipolar radiofrequency device (Cardioblate; Medtronic, Minneapolis, Minnesota, USA). On confirming reversion to sinus rhythm and after cross-clamping the ascending aorta, antegrade cardioplegia was induced. The graft was passed sequentially through the left retroperitoneum, the diaphragm, and the left thoracic cavity while under cardiac arrest. Then, an end-to-side anastomosis was created between the graft and the ascending aorta, avoiding the area of calcification in the ascending aorta. Finally, in the left thoracic cavity, an end-to-end anastomosis was created between the proximal and distal grafts and the branched 7-mm graft was ligated. The
671
2013/09/11
15:33:43
Obata S, et al.
(A)
(B)
Fig. 3 Postoperative imaging results. (A) Three-dimensional computed tomography (3D CT) shows a satisfactory graft and no stenosis of the abdominal vessels. (B) Thoracic X-ray. Cardiothoracic ratio (CTR) is 57%. Improvement of both cardiomegaly and pulmonary congestion is evident.
patient was started on oral steroids postoperatively, and no pressure gradient was observed between the upper and lower limbs on manometry. Hypertension could be well controlled by a b-blocker alone. Heart rate was maintained in sinus rhythm, and chest X-ray showed improvement of the cardiomegaly (Fig. 3A). Postoperative CT showed good graft patency (Fig. 3B). As the patient’s course was favorable, she was discharged in remission on postoperative day 15.
Discussion Atypical coarctation of the aorta is an arteriosclerotic disease frequently affecting the thoracic ascending and descending aorta, as well as the abdominal aorta. There is no stenosis of the branches of the aortic arch, and when the stenotic lesions are confined to the abdominal aorta, it is referred to as “midaortic syndrome”. While there are several causes of aortic coarctation, aortitis syndrome is the most common cause. The patient’s condition results in central hypertension and failure of peripheral perfusion in the region of coarctation. Cardiac failure in particular exerted a significant influence on
672
AVD-CR 13-00039 Obata_P.indd
prognosis of the present patient.1) Her uncontrollable hypertension over the long term and accompanying hypertensive cardiac failure made her a candidate for surgical treatment.1,2) Various surgical techniques can be used in adults with atypical coarctation of the aorta arising from the region of coarctation and its surroundings, including vascular prosthesis implantation, patch-angioplasty, aorto-aortic bypass, and axillo-bifemoral bypass.3-5) The reason we selected ascending aorta-abdominal aorta bypass was because, despite it requiring a median sternotomy incision to the abdomen, we were able to use a large caliber vascular graft and thus expected to ensure a reliably alleviated afterload, long-term vascular graft patency, and satisfactory perfusion of the abdominal branching vessels. In addition, as we intended to perform pulmonary vein isolation for the atrial fibrillation, it was possible to obtain a good field of view of the ascending aorta and the expansion of the heart by midline sternotomy, and it was easy and safe to establish extracorporeal circulation.6) Routes that can be selected for ascending aorta-abdominal aorta bypass are intra-abdominal, retroperitoneal (anterior pancreatic aspect and posterior pancreatic region), and
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
672
2013/09/11
15:33:44
Left Thoracic Ascending-Abdominal Aorta Bypass
beneath the rectum abdominis, but the retroperitoneal route is generally chosen because it does not allow contact between the gastrointestinal system and the vascular graft.6) However, the retroperitoneal route passes over the anterior aspect of the liver, continues through an aperture in the lesser omentum, and requires the graft to pass through the peritoneum. In addition, whether the anterior or posterior route to the pancreas is chosen, dissection around the pancreas is required, which carries a risk of postoperative pancreatitis. For this reason, the vascular graft in the present case was guided via the left thoracic cavity from the retroperitoneum to the abdominal aorta and anastomosed, making it possible to avoid exposing the graft to the intraperitoneal and peripancreatic procedures. In addition, using the route through the left thoracic cavity makes it possible to bypass the direct bifurcation of the left subclavian artery if necessary. On the other hand, a long vascular graft was required, but large-caliber vessels are usually considered to retain their patency.7) With regard to extracorporeal circulation, there were concerns that the vascular characteristics of the anastomosed region were fragile. As the patient had obvious hypertensive complications, partial aortic clamping was not used, and extracorporeal circulation under cardiac arrest was considered safer for creating a sufficiently large anastomotic opening in the central side of the ascending aorta. In addition, as it was safer and more reliable to conduct pulmonary vein isolation for the atrial fibrillation, perfusing the abdominal organs below the region of stricture was considered extremely useful before creating the anastomosis to the abdominal aorta. The patient’s postoperative course was uneventful and recovery was good. However, due to the possibility of relapse or postoperative exacerbation of aortitis, which would cause closure or stricture of the carotid bifurcations, the patient was administered oral steroids and strictly followed. Continued control of arteritis and hypertension is necessary to improve prognosis.8)
Annals of Vascular Diseases Vol. 6, No. 3 (2013)
AVD-CR 13-00039 Obata_P.indd
673
Conclusion Ascending aorta-abdominal aorta bypass grafting via the left thoracic cavity may be a safe and useful procedure for patients with uncontrollable hypertension caused by atypical coarctation of the aorta.
Disclosure Statement The authors declare no conflicts of interest.
References 1) Aris A, Subirana MT, Ferrés P, et al. Repair of aortic coarctation in patients more than 50 years of age. Ann Thorac Surg 1999; 67: 1376-9. 2) Taketani T, Miyata T, Morota T, et al. Surgical treatment of atypical aortic coarctation complicating Takayasu’s arteritis—experience with 33 cases over 44 years. J Vasc Surg 2005; 41: 597-601. 3) Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000; 70: 31-7. 4) Tanaka M, Hirayama T, Yusa H, et al. A successful case of ascending aorta-abdominal aorta bypass in a patient with atypical coarctation. Jpn J Cardiovasc Surg 2007; 36: 132-6. 5) Kiji T, Kijima Y, Yamaguchi A. Axillo-bifemoral artery bypass for atypical coarctation. Jpn J Cardiovasc Surg 2000; 29: 94-7. 6) Inagaki E, Hamanaka S, Minami K, et al. Three cases of ascending aorta-abdominal aorta bypass for atypical coarctation with Takayasu’s aortitis. Jpn J Cardiovasc Surg 2009; 38: 239-43. 7) Almeida de Oliveira S, Lisboa LA, Dallan LA, et al. Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results. Ann Thorac Surg 2003; 76: 1962-6. 8) Miyata T, Sato O, Deguchi J, et al. Anastomotic aneurysms after surgical treatment of Takayasu’s arteritis: a 40-year experience. J Vasc Surg 1998; 27: 438-45.
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15:33:44
