Ann Thorac Surg 1997;64:1072-1074
© 1997 The Society of Thoracic Surgeons
Original Article: Cardiovascular
Late Results of Patch Repair of Coarctation of the Aorta in Adults Using Autogenous Arterial Wall
W. Andrew Owens, FRCS,
Michael J. Tolan, Frcs(i),
Jack Cleland, FRCS
Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
Accepted for publication April 15, 1997.
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Abstract
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Background. Interposition grafting or patch repair of adult coarctations of the aorta are the standard methods of surgical treatment. Both involve use of prosthetic material, and patch repair using prosthetic material may lead to aneurysm formation in the long term.
Methods. Four patients aged 17 to 29 years had been investigated for systemic hypertension and had coarctation of the aorta diagnosed on cardiac catheterization. Between March and November 1984, all 4 underwent a corrective operation. The lesions were widely incised and a broad patch of ipsilateral mammary or Abbott's artery was fashioned across the narrowing. The arteries had been enlarged in diameter because of prolonged exposure to high blood pressure as collateral vessels, although none was intrinsically diseased.
Results. After 12 years of follow-up, only 1 patient remains on antihypertensive therapy. Spiral computed tomographic reconstructions revealed only very mild residual stenosis in 1 patient, confirmed by subsequent aortography.
Conclusions. In adult patients with coarctation of the aorta, the use of the enlarged internal mammary artery as a patch graft is a simple, quick procedure, which may give lasting relief of obstruction. Spiral computed tomographic scanning is an ideal noninvasive method of follow-up.
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Introduction
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The technique of patch aortoplasty for repair of coarctation of the aorta was first described in 1957 by Vosschulte [1] and has since become a popular method of repair, particularly where end-to-end anastomosis would be particularly difficult and in adult patients. Aneurysm formation in the aorta opposite the site of patch repair using prosthetic material has been reported in up to 35% of patients in whom this technique has been used, particularly in adolescence or adulthood [2, 3].
In this report we present the results of patch aortoplasty using autogenous vessel wall as the graft material, and reviewed more than 10 years postoperatively using echocardiography and dynamically enhanced spiral computed tomographic (CT) scanning with three-dimensional reconstruction.
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Patients and Methods
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Between March and November 1984, four male patients aged 17, 23, 24, and 29 years (mean, 23 years) underwent repair of coarctation of the aorta using a segment of native vessel as graft material for patch aortoplasty. All the coarctations had been detected during medical examination for unrelated conditions and were investigated with echocardiography and cardiac catheterization before surgical referral. Preoperative features of the individual patients are shown in Table 1
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The intrathoracic aorta was approached via a left posterolateral thoracotomy. The pleura overlying the descending aorta was incised and the area of the coarctation mobilized. At this stage, a 4- to 5-cm segment of the vessel to be used for graft material was excised and the vessel ligated proximally and distally. In 3 cases the vessel used was the dilated left internal mammary artery; in the fourth it was a large, dilated vessel in the position of Abbott's artery. The ligamentum arteriosum was then ligated, the aorta clamped proximally and distally, the coarctation opened longitudinally, and any obstructing ridge excised. The patch was then trimmed to size and sutured in place using a continuous 4/0 polypropylene suture.
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Results
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All patients were reviewed 12 years after the operation. This included full physical examination, review of medication, transthoracic echocardiography (transesophageal echocardiography in addition in patient 3), and spiral CT scanning. There was no perioperative mortality or significant morbidity, and 12 years later all patients are alive and fully active. One patient is soon to have an operation for aortic valve regurgitation. One patient had aortography in addition to the echocardiographic and CT imaging.
The results at 12 years of follow-up on individual patients are presented in Table 2. None of the patients had a measurable difference between arm and leg blood pressures on clinical examination. Blood pressure in the 2 patients without associated aortic valve anomalies has returned to normal levels without the need for antihypertensive medication. One patient requires antihypertensive treatment but has a degree of aortic stenosis. Patient 3 has clinical and Doppler findings consistent with the presence of severe aortic regurgitation causing a spuriously high estimation of gradient across the repair. Three of the four CT scans showed no significant abnormalities. Only patient 4 had an abnormal CT scan (Fig 1), and the impression it gave of mild stenosis at the repair site was confirmed by aortography (Fig 2), but no significant gradient could be detected across the site of repair by echocardiography.
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Fig l. . Three-dimensional reconstruction of computed tomographic scan demonstrating residual stenosis at repair site (patient 4).
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Comment
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Patch repair of coarctation of the aorta is a well-established technique that involves minimal mobilization of the aorta and collateral vessels. This technique also enables relatively easy management of proximal and distal size discrepancy [1]. Prosthetic material is routinely used for the patch, but there is a well-recognized risk of aneurysm formation occurring in the aortic wall opposite the site of this repair. The risk appears to be highest in those repairs performed in adult life and is probably unrelated to resection of the intimal ridge at this site [2].
The lack of elasticity of the prosthetic patch may lead to turbulent flow and abnormal stresses in the aortic wall opposite the repair, thus predisposing to aneurysm formation. None of the patients in this study showed any evidence of aneurysm formation more than 10 years after the original operation. It is not unreasonable to suggest that this is because of the aortic wall and native vessel patch having similar elastic properties. A further theoretic advantage is the avoidance of foreign material and the potential risks associated with its use. Not all patients will have suitable vessels to use as patch material, but in this young adult population, the internal mammary artery is dilated but the wall is still relatively disease-free, making this the group in which the technique is most likely to be applicable.
Despite the relatively long follow-up period of this study, we recognize that aneurysmal changes are a late phenomenon and can appear 20 years after the initial procedure. Continued follow-up will be necessary in these patients and, with the small numbers reported, more long-term studies are required to fully evaluate this technique.
Moor and associates [4] were the first to describe the use of a segment of autogenous internal mammary artery as patch material in 1972. Campalani and colleagues [5] described 23 patients in whom the technique had been used successfully over a 17-year period. Although endorsing the technique, their study includes an unspecified number of pediatric patients, a population in whom other techniques have a more established role. They also have a wide range of follow-up (1 month to 11 years; mean ± standard deviation; 4.4 ± 3.65 years) and do not specify the imaging techniques used at follow-up. An unusual feature of our study is the use of dynamically enhanced spiral CT scans with three-dimensional reconstructions. This technique is particularly valuable in the detection of early aneurysm formation, which may not be visualized by standard chest roentgenograms, while avoiding the inconvenience and risks of aortography. There may be a role for the use of this technique to allow early and accurate aneurysm detection in the routine follow-up of all patients in whom prosthetic patches have been used.
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Footnotes
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Address reprint requests to Mr Owens, Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, United Kingdom.
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References
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- Vosschulte K. Surgical correction of coarctation of the aorta by an `isthmusplastic' operation. Thorax 1961;16:338–45.[Free Full Text]
- Aebert H, Laas J, Bednarski P, Koch U, Pokop M, Borst HG. High incidence of aneurysm formation following patch plasty repair of coarctation. Eur J Thorac Surg 1993;7:200–5.
- Ala-Kulju K, Heikkinen L. Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management. Ann Thorac Surg 1989;47:853–6.[Abstract]
- Moor GF, Ionescu MI, Ross DN. Surgical repair of coarctation of the aorta by patch grafting. Ann Thorac Surg 1972;14:626–30.[Medline]
- Campalani G, Firmin RK, Vaughan M, Ross DN. Surgical repair of coarctation of the aorta using the internal mammary artery as a free autogenous graft. J Thorac Cardiovasc Surg 1985;90:928–31.[Medline]
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Abstract
Introduction
