Complex coarctation of the aorta requiring a third redo operation

Complex coarctation of the aorta requiring a third redo operation Abstract Coarctation of the aorta can require multiple redo surgeries. It is extremely pertinent to plan for this and ensure that each operation is performed with future repair in mind. We present a rare case and the subsequent management of competitive flow in coarctation of the aorta requiring a fourth operation for repair. Aorta , Coarctation of aorta , Reoperation , Congenital , Grown-up congenital heart INTRODUCTION We describe our unit’s challenging case of a fourth time redo for coarctation of the aorta. CASE REPORT A 51-year-old woman presented with acute shortness of breath [New York Heart Association (NYHA) III]. A clinical diagnosis of congestive cardiac failure was present with a subsequent background of warfarin therapy for a recent pulmonary embolism. The surgical history included 3 repairs for coarctation of the aorta at 5, 12 and 29 years of age with a 13-mm graft and a 20-mm graft at 12 and 29 years of age, respectively. A resection and direct end-to-end anastomosis were performed at the age of 5 years. All previous operations were performed at another international cardiothoracic unit. Imaging demonstrated a thrombosed 20-mm graft and a 5.5-cm pseudoaneurysm at the junction between the distal arch and the proximal descending aorta. The previous 13-mm graft was anatomically parallel with a 20-mm graft. It had not been ligated and was patent (Video 1). This is also demonstrated on reconstructed 3-dimensional imaging (Video 2). The EuroSCORE II for a fourth time repair was 34.5. The patient underwent a fourth operation and a third redo left posterolateral thoracotomy with femoral–femoral bypass. The proximal and distal control was achieved by clamping the native aorta. As the case was a chronic process with multiple redo surgeries, the lumbar and segmental arteries were non-existent and reliant upon collateral circulation. The area encompassed the false aneurysm and the entirety of both existing grafts (Fig. 1). Both previous graft sites (13-mm and 20-mm grafts) were resected (Fig. 2) and replaced with a 24-mm interposition graft with end-to-end anastomosis, and all lumbar vessels were ligated. Video 1 Preoperative computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Video 1 Preoperative computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Close Video 2 Preoperative 3-dimensional reconstructed computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Video 2 Preoperative 3-dimensional reconstructed computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Close Figure 1: View largeDownload slide Left posterolateral thoracotomy with a 5.5-cm pseudoaneurysm on view. Figure 1: View largeDownload slide Left posterolateral thoracotomy with a 5.5-cm pseudoaneurysm on view. Figure 2: View largeDownload slide Excised 20-mm graft with severe thrombosis. Figure 2: View largeDownload slide Excised 20-mm graft with severe thrombosis. DISCUSSION The current literature describes the detrimental effects of competitive flow in coronary and peripheral vascular surgeries [1, 2]. In particular, it has been stated for coronary surgery that flow competition results from an equilibrium between the residual flow through the native coronary artery and the flow provided by the bypass graft at the anastomosis [3]. The patent 13-mm graft acts as the native coronary artery, and the 20-mm graft acts as the bypass graft. In this case report, the same principles apply when 2 patent grafts exist for coarctation. In this instance, the failed third repair is believed to be a direct consequence of failure of ligation in the previous second repair. A competitive flow rate in the smaller 13-mm graft is directly responsible for the thrombosis of the 20-mm graft. When repairing previous graft sites, it is imperative to establish uninhibited flow rates. This case also reiterates the necessity for long-term surveillance in patients with a repaired coarctation of the aorta as there is a significant long-term risk of morbidity and mortality [4, 5]. The long-term surveillance is not just pertinent to follow anatomical progression of the disease but also to monitor modifiable risk factors that are pertinent to coarctation of the aorta such as controlling hypertension [5]. Redo cardiothoracic surgery, especially of the thoracic aorta, requires careful planning. It is crucial to involve members of a multidisciplinary team, to review clinical imaging preoperatively and to develop contingency plans for operative management. Conflict of interest: none declared. REFERENCES 1 Li M, Liu S, Zhang J, Lu Z, Wei M, Chun EJ et al.   Coronary competitive reverse flow: imaging findings at CT angiography and correlation with invasive coronary angiography. J Cardiovasc Comput Tomogr  2015; 9: 202– 8. Google Scholar CrossRef Search ADS PubMed  2 Jelenc M, Jelenc B, Klokocovnik T, Lakic N, Gersak B, Knezevic I. Understanding coronary artery bypass transit time flow curves: role of bypass graft compliance. Interact CardioVasc Thorac Surg  2014; 18: 164– 8. Google Scholar CrossRef Search ADS PubMed  3 Glineur D, Hanet C. Competitive flow and arterial graft a word of caution. Eur J Cardiothorac Surg  2012; 41: 768– 9. Google Scholar CrossRef Search ADS PubMed  4 Choudhary P, Canniffe C, Jackson DJ, Tanous D, Walsh K, Celermajer DS. Late outcomes in adults with coarctation of the aorta. Heart  2015; 101: 1190– 5. Google Scholar CrossRef Search ADS PubMed  5 Vonder Muhll IF, Sehgal T, Paterson DI. The adult with repaired coarctation: need for lifelong surveillance. Can J Cardiol  2016; 32: 1038.e11– 5. Google Scholar CrossRef Search ADS   © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Complex coarctation of the aorta requiring a third redo operation

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
eISSN
1569-9285
D.O.I.
10.1093/icvts/ivy130
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Abstract

Abstract Coarctation of the aorta can require multiple redo surgeries. It is extremely pertinent to plan for this and ensure that each operation is performed with future repair in mind. We present a rare case and the subsequent management of competitive flow in coarctation of the aorta requiring a fourth operation for repair. Aorta , Coarctation of aorta , Reoperation , Congenital , Grown-up congenital heart INTRODUCTION We describe our unit’s challenging case of a fourth time redo for coarctation of the aorta. CASE REPORT A 51-year-old woman presented with acute shortness of breath [New York Heart Association (NYHA) III]. A clinical diagnosis of congestive cardiac failure was present with a subsequent background of warfarin therapy for a recent pulmonary embolism. The surgical history included 3 repairs for coarctation of the aorta at 5, 12 and 29 years of age with a 13-mm graft and a 20-mm graft at 12 and 29 years of age, respectively. A resection and direct end-to-end anastomosis were performed at the age of 5 years. All previous operations were performed at another international cardiothoracic unit. Imaging demonstrated a thrombosed 20-mm graft and a 5.5-cm pseudoaneurysm at the junction between the distal arch and the proximal descending aorta. The previous 13-mm graft was anatomically parallel with a 20-mm graft. It had not been ligated and was patent (Video 1). This is also demonstrated on reconstructed 3-dimensional imaging (Video 2). The EuroSCORE II for a fourth time repair was 34.5. The patient underwent a fourth operation and a third redo left posterolateral thoracotomy with femoral–femoral bypass. The proximal and distal control was achieved by clamping the native aorta. As the case was a chronic process with multiple redo surgeries, the lumbar and segmental arteries were non-existent and reliant upon collateral circulation. The area encompassed the false aneurysm and the entirety of both existing grafts (Fig. 1). Both previous graft sites (13-mm and 20-mm grafts) were resected (Fig. 2) and replaced with a 24-mm interposition graft with end-to-end anastomosis, and all lumbar vessels were ligated. Video 1 Preoperative computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Video 1 Preoperative computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Close Video 2 Preoperative 3-dimensional reconstructed computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Video 2 Preoperative 3-dimensional reconstructed computed tomography demonstrating a thrombosed 20-mm graft with a 5.5-cm pseudoaneurysm at the proximal end. Close Figure 1: View largeDownload slide Left posterolateral thoracotomy with a 5.5-cm pseudoaneurysm on view. Figure 1: View largeDownload slide Left posterolateral thoracotomy with a 5.5-cm pseudoaneurysm on view. Figure 2: View largeDownload slide Excised 20-mm graft with severe thrombosis. Figure 2: View largeDownload slide Excised 20-mm graft with severe thrombosis. DISCUSSION The current literature describes the detrimental effects of competitive flow in coronary and peripheral vascular surgeries [1, 2]. In particular, it has been stated for coronary surgery that flow competition results from an equilibrium between the residual flow through the native coronary artery and the flow provided by the bypass graft at the anastomosis [3]. The patent 13-mm graft acts as the native coronary artery, and the 20-mm graft acts as the bypass graft. In this case report, the same principles apply when 2 patent grafts exist for coarctation. In this instance, the failed third repair is believed to be a direct consequence of failure of ligation in the previous second repair. A competitive flow rate in the smaller 13-mm graft is directly responsible for the thrombosis of the 20-mm graft. When repairing previous graft sites, it is imperative to establish uninhibited flow rates. This case also reiterates the necessity for long-term surveillance in patients with a repaired coarctation of the aorta as there is a significant long-term risk of morbidity and mortality [4, 5]. The long-term surveillance is not just pertinent to follow anatomical progression of the disease but also to monitor modifiable risk factors that are pertinent to coarctation of the aorta such as controlling hypertension [5]. Redo cardiothoracic surgery, especially of the thoracic aorta, requires careful planning. It is crucial to involve members of a multidisciplinary team, to review clinical imaging preoperatively and to develop contingency plans for operative management. Conflict of interest: none declared. REFERENCES 1 Li M, Liu S, Zhang J, Lu Z, Wei M, Chun EJ et al.   Coronary competitive reverse flow: imaging findings at CT angiography and correlation with invasive coronary angiography. J Cardiovasc Comput Tomogr  2015; 9: 202– 8. Google Scholar CrossRef Search ADS PubMed  2 Jelenc M, Jelenc B, Klokocovnik T, Lakic N, Gersak B, Knezevic I. Understanding coronary artery bypass transit time flow curves: role of bypass graft compliance. Interact CardioVasc Thorac Surg  2014; 18: 164– 8. Google Scholar CrossRef Search ADS PubMed  3 Glineur D, Hanet C. Competitive flow and arterial graft a word of caution. Eur J Cardiothorac Surg  2012; 41: 768– 9. Google Scholar CrossRef Search ADS PubMed  4 Choudhary P, Canniffe C, Jackson DJ, Tanous D, Walsh K, Celermajer DS. Late outcomes in adults with coarctation of the aorta. Heart  2015; 101: 1190– 5. Google Scholar CrossRef Search ADS PubMed  5 Vonder Muhll IF, Sehgal T, Paterson DI. The adult with repaired coarctation: need for lifelong surveillance. Can J Cardiol  2016; 32: 1038.e11– 5. Google Scholar CrossRef Search ADS   © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Apr 24, 2018

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