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Ann Thorac Surg 2000;70:31-37
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy

^a Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Address reprint requests to Dr Schaff, Section of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905
e-mail: schaff{at}mayo.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair.

Methods. Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 ± 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu’s aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients.

Results. No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 ± 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta.

Conclusions. Exposure of the descending aorta through the posterior pericardium for ascending aorta–descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be further complicated when associated cardiac defects require repair and there is no consensus on the optimal approach. Indeed, anatomic repair of the diseased segment of the descending aorta may not be possible because of previous operations. Various techniques of extraanatomic bypass grafting from the ascending aorta have been described, including methods in which the distal anastomosis is performed on the descending thoracic aorta, the supraceliac abdominal aorta, or the infrarenal abdominal aorta [1–6].

Exposure of the descending thoracic aorta through a median sternotomy and the posterior pericardium was described by Vijayanagar and colleagues [7] and subsequently modified by Sweeney and associates [5], whose alternate approach permits simultaneous intracardiac repair when necessary. We report 17 consecutive patients in whom the posterior pericardial approach to the descending aorta was used and discuss the indications, techniques, and results.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
We reviewed the hospital records, operative notes, and follow-up clinic records of 17 patients who underwent ascending aorta-to-descending aorta bypass grafting through a median sternotomy and posterior pericardial approach between December 1985 and February 1998 at the Mayo Medical Center. Demographic characteristics of the patients are presented in Table 1. The ages of the 13 men and 4 women ranged from 16 to 76 years (mean, 47.6 ± 18.5 years). Preoperatively, all patients had echocardiography, 16 had aortography, and 12 had coronary angiography. Eleven patients had previously undergone cardiac or thoracic aortic operations (Table 2). Concomitant procedures were performed in 12 patients (Table 3).

View larger version (60K): [in this window] [in a new window]   Fig 3. (Patient 10, Table 3.) Complex descending aortic arch aneurysm. (A) Preoperative magnetic resonance image (MRI) of the chest (sagittal section). The aneurysm begins immediately distal to the origin of the subclavian artery (short arrow). The right innominate and left common carotid arteries have a common origin (long arrow). (B) Postoperative MRI of the chest demonstrated a widely patent graft from descending thoracic aorta to ascending aorta (long arrow). No flow is seen within the excluded aneurysm (short arrow).

View larger version (67K): [in this window] [in a new window]   Fig 4. (Patient 11, Table 3.) Severe ulcerative atherosclerosis. (A) Contrast computed tomographic scan of the chest demonstrates a large plaque along the lateral wall of the descending thoracic aorta (arrow), with significant narrowing of the lumen. (B) Postoperative aortography shows a patent ascending aorta-to-descending aorta graft (long arrow). No flow is seen in the excluded proximal descending thoracic aorta (short arrow).

View larger version (63K): [in this window] [in a new window]   Fig 5. (Patient 17, Table 3.) Coarctation of the aorta after repair of traumatic transection of descending thoracic aorta. Postoperative spiral computed tomographic scan of the chest, serially reconstructed images. (A) Anterolateral view demonstrates the course of the ascending aorta-to-descending (Asc-Des) aorta bypass graft. (B) Posterior view shows bypass graft and coarctation at the descending (Des) thoracic aorta. (Ao = aortic; PA = pulmonary artery; SVC = superior vena cava.)

Preoperative diagnoses in group 1 included recurrent coarctation of the aorta (n = 4), coarctation of the aorta (n = 4), Takayasu’s aortitis (n = 1), complex descending aortic arch aneurysm (n = 1), severe aortic atherosclerosis (n = 1), and a false aneurysm of the descending aorta at a site of previous graft repair of coarctation (n = 1). Associated cardiac problems in this group included coronary artery disease (n = 3), mitral valve regurgitation (n = 3), aortic valve stenosis (n = 2), aortic valve regurgitation (n = 1), prosthetic aortic valve stenosis (n = 1), and hypertrophic obstructive cardiomyopathy (n = 1).

The preoperative diagnoses in the second group (patients 13 to 17; Table 3) included chronic descending aortic dissection (n = 1), recoarctation of aorta (n = 1), Takayasu’s aortitis (n = 1), long-segment stenosis of the descending aorta (n = 1), and acquired coarctation of aorta after previous repair of traumatic transection of the descending aorta.

Operative technique
A median sternotomy was performed in all patients. Hypothermic (16°C to 34°C) cardiopulmonary bypass (mean time, 120 ± 65 minutes; range, 18 to 217 minutes) was established after aortic and right atrial cannulation. Femoral artery cannulation was used in 1 patient. In all patients, the descending thoracic aorta was exposed through the posterior pericardium by retracting the heart cephalad and incising the pericardium longitudinally.

The descending aorta was controlled with a partially occluding vascular clamp, and the end-to-side graft-to-aorta anastomosis was made with continuous 4-0 polypropylene suture (Fig 1). The graft was led anterior to the esophagus and routed posterior to the inferior vena cava but anterior to the right inferior pulmonary vein (Fig 2). The graft was then cut obliquely and anastomosed to the right lateral aspect of the ascending aorta, using a side-biting clamp.

View larger version (56K): [in this window] [in a new window]   Fig 1. Exposure of the descending thoracic aorta through the posterior pericardium. The heart is retracted by the assistant as partial aortic clamping is applied to the descending aorta, and the distal anastomosis is performed.

View larger version (54K): [in this window] [in a new window]   Fig 2. (Patient 7, Table 3.) In a patient with coarctation of the aorta and coronary artery disease, the course of the ascending aorta-to-descending aorta bypass graft is shown. The graft is led from the descending thoracic aorta to the ascending aorta and routed posterior to the inferior vena cava to the right lateral aspect of the ascending aorta. A concomitant aortocoronary bypass graft was performed. (Asc = ascending; Des = descending; IMA = internal mammary artery; IVC = inferior vena cava; R = right.)

In the 12 patients undergoing concomitant operations, the cardiac procedures were accomplished after performing the distal anastomosis of the graft to the descending aorta. In 9 of these patients, the heart was arrested using cold crystalloid (n = 1) or cold blood (n = 8) cardioplegia, antegrade (n = 9) or retrograde (n = 1) (mean cross-clamp time, 56 ± 33 minutes; range, 23 to 128 minutes). In 3 patients, we did not arrest the heart with cardioplegia. The first patient (patient 10, Table 3) was a 75-year-old man with a complex descending aortic arch aneurysm associated with coronary artery disease (Fig 3). Aortic cross-clamping was avoided because of severe calcification of the ascending aorta. The distal coronary anastomosis was performed with coronary perfusion, and proximally the vein graft was anastomosed to the descending aortic graft. The second patient (patient 9, Table 3) was a 20-year-old woman with Takayasu’s aortitis that caused severe coarctation of the aortic arch and proximal descending aorta and stenosis of the brachiocephalic vessels. In this patient, the innominate and left common carotid arteries were reconstructed with a Dacron prosthesis fashioned as a Y graft and anastomosed proximally to the ascending aorta-to-descending aorta graft. The third patient (patient 12, Table 3) was a 47-year-old woman with a false aneurysm of the descending aorta at a site of previous graft repair of coarctation of the aorta, next to the origin of the left subclavian artery. In this patient, the subclavian artery was reconstructed with a Dacron bypass graft from the left common carotid artery.

Deep hypothermia and total circulatory arrest (mean arrest time, 25 ± 15 minutes; range, 10 to 49 minutes; temperature, 16°C to 20°C) was used in 4 patients to facilitate construction of the distal anastomosis to the descending aorta (patients 1, 4, 13, 17; Table 3), and in 2 patients when replacing the aortic arch (patient 11, Table 3) and excluding a false aneurysm of the descending aorta (patient 12, Table 3).

In 4 patients, the diseased segment of the descending thoracic aorta was excluded from the circulation. The first patient (patient 13) was a 69-year-old man with a previous repair of a descending aortic dissection using an interposition tube graft in whom a false channel developed around the graft and extended beyond the distal anastomosis into the abdomen. The aorta was divided at the diaphragmatic hiatus, and the bypass graft was anastomosed to the distal aorta; the proximal end of the descending thoracic aorta was oversewn. The distal end of the aortic arch was transected obliquely just distal to the left subclavian artery. In this way, we interrupted the aorta and excluded the aneurysmal descending aorta from the circulation.

The second patient (patient 10, Table 3) was a 75-year-old man with coronary artery disease and a 10-cm aneurysm of the distal aortic arch originating just beneath the orifice of the left subclavian artery (Fig 3). This patient also had the additional anomaly of the left common carotid artery originating from the innominate artery. We first divided the left subclavian artery proximally and performed a bypass graft, Hemashield 8 mm, from the left common carotid (end-to-side) to the subclavian artery (end-to-side). After the ascending aorta-to-descending aorta bypass graft had been completed, the aneurysm was opened and excised. The proximal aortic arch beneath the innominate artery was oversewn, as was the origin of the left subclavian artery. The distal aortic arch was near-normal in size, and we used a Dacron patch to facilitate secure intraluminal closure; by this method, we excluded the aneurysmal segment from the circulation.

The third patient in whom we used this exclusion technique was a 68-year-old man with recurrent peripheral embolization due to severe ulcerative atherosclerosis of the ascending aorta, aortic arch, and descending thoracic aorta (patient 11, Table 3, Fig 4). The ascending aorta and arch were excised and replaced with a 30-mm Hemashield tube graft that was sewn proximally to the aorta at the sinotubular junction and distally to the brachiocephalic vessels. The descending thoracic aorta was oversewn and excluded, and an ascending aorta-to-descending aorta bypass graft was performed.

The fourth patient was a 47-year-old woman with a thin false aneurysm of the descending aorta at the site of a previous graft repair of coarctation of the aorta (patient 12, Table 3). After the ascending aorta-to-descending aorta graft had been performed, using deep hypothermia and total circulatory arrest, the distal aortic arch was transected. The proximal aortic arch beneath the innominate artery was oversewn. The distal end was the previous graft, which had disrupted at both the proximal and distal suture line. Therefore, it was excised, and the descending aorta was oversewn at the level of the hilum of the lung.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was no hospital or late mortality. Perioperative morbidity consisted of pneumonia (n = 1), mild renal failure (n = 1), prolonged intubation (larger than 24 hour, n = 1), and reoperation to control bleeding (n = 1). None of the patients in whom deep hypothermia and total circulatory arrest was used had neurologic deficit. Mean hospital stay was 8.8 ± 3.5 days (range, 5 to 17 days).

Follow-up was 100% complete and extended to 12 years (mean, 2.7 ± 3.3 years). One patient who had a concomitant mitral valve replacement underwent successful repair of perivalvular leak. One patient with a severe ulcerative atherosclerotic aorta and recurrent embolization to the abdominal viscera and lower extremities underwent resection of the lower thoracic and abdominal aorta with aortic bilateral femoral bypass graft. There were no late graft-related complications or reoperations. All grafts are widely patent, as documented with follow-up echocardiography. Three patients had postoperative imaging studies: magnetic resonance imaging (patient 10, Table 3, Fig 3), aortography (patient 11, Table 3, Fig 4), and computed tomography (patient 17, Table 3, Fig 5).

Nine patients had a diagnosis of coarctation or recoarctation of the aorta, and all patients had been treated for hypertension. At follow-up, only 1 patient continued to take medication to control high blood pressure.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Various surgical procedures have been used for repair of complex forms of descending aortic disease, including anatomic repair and extraanatomic bypass grafting [1–8]. Anatomic repair often requires extensive mobilization of the aorta and control of collateral blood vessels; potential complications include bleeding from adhesions, parenchymal lung injury, damage to the recurrent laryngeal or phrenic nerves, chylothorax, and spinal cord ischemia [9]. Paraplegia remains the most feared complication, and risk increases with prolonged aortic cross-clamp time and older age [9].

In an early report by Edie and colleagues [1], 4 patients with recurrent coarctation of the aorta underwent ascending aorta-to-descending aorta bypass grafting through a combined left thoracotomy and median sternotomy. Later, Jacob and associates [10] reported satisfactory long-term results in 10 patients who had been operated on with the same technique. In a report of operations for recurrent coarctation of the aorta, Sweeney and associates [5] from the Texas Heart Institute described 16 patients who had bypass grafting around the coarctation. In 12 patients, the graft was inserted through a left thoracotomy, and in the other 4, the graft from the ascending to descending aorta was established through a median sternotomy.

When associated cardiac defects require repair, two surgical approaches have been described: a one-stage correction of both lesions simultaneously through a median sternotomy [5–7, 9, 11–15] and a two-stage repair through a median sternotomy and thoracotomy [16]. Exposure of the descending thoracic aorta through the posterior pericardium in performing ascending aorta-to-descending aorta bypass grafting was described by Vijayanagar and colleagues [7] in 1980 in an adult with coarctation of the aorta associated with severe aortic valve regurgitation. In this patient, the graft was placed around the left margin of the heart, traversing the pericardium and the left pleural cavity, anterior to the left pulmonary hilum, and was anastomosed proximally to the medial aspect of the ascending aorta. In 1983, Powell and associates [14] described a modification of this technique in 4 patients in whom the graft was routed around the right margin of the heart and anastomosed proximally to the right lateral aspect of the ascending aorta.

Since these initial descriptions, the posterior pericardial approach to the descending aorta has been adopted by other investigators, and 22 cases, in various modifications, have been reported in the English language literature [5–7, 9, 11–14]. We used this approach in 17 consecutive patients. We led the graft between the inferior vena cava and the right inferior pulmonary vein, a route that keeps the graft in a more posterior location without compression of the right atrium and, thus, may protect the prosthesis if sternal reentry is necessary.

This experience with the posterior pericardial approach to the descending aorta includes a heterogeneous group of patients with complex forms of descending aortic disease. Two-thirds of the patients had associated cardiac or great vessel problems that were repaired simultaneously, and 65% had previous cardiac or thoracic operations.

Ten patients had native coarctation, recurrent coarctation, or acquired coarctation of the aorta. The reported incidence of recurrent coarctation of the aorta is 5% to 10% [4], and no single method of repair is applicable in all patients [3–5, 8]. When associated cardiac defects require repair, a one-stage approach using cardiopulmonary bypass and ascending aorta-to-descending aorta bypass grafting through the posterior pericardium is a safe technique that avoids the potential complications of anatomic repair and reoperation and allows a concomitant repair through the same incision.

In 1996, Pethig and associates [17] reported hemodynamic instability in 2 patients early after combined aortic valve replacement and extraanatomic bypass of coarctation of the aorta. They speculated that myocardial ischemia developed when diastolic perfusion pressure was decreased in severely hypertrophied hearts. We have not observed this phenomenon in our 10 patients with the diagnosis of coarctation or recoarctation of the aorta. An alternative method is the two-stage repair of adult coarctation associated with congenital valvular disease [16].

Other indications for using this approach were Takayasu’s disease, severe atherosclerosis, and complex descending thoracic aortic aneurysm. Two patients with Takayasu’s disease (patients 9 and 15) had stenotic lesions involving the descending thoracic aorta, aortic arch, and arch great vessels, causing obstructive symptoms and signs. In 1994, Robbs and colleagues [18] reviewed an extensive experience with reconstructive surgery in 134 patients with Takayasu’s disease. Operative management included reconstruction of the aortic arch, interposition grafts, or local bypass grafting, with good long-term results. We elected to perform an ascending aorta-to-descending aorta bypass graft in our 2 patients to minimize risk and allow simultaneous reconstruction of the brachiocephalic arteries.

Surgical approaches to symptomatic patients with atherosclerotic disease of the aorta include endarterectomy, resection and reconstruction, and extraanatomic bypass grafting [19]. In our series, 1 patient underwent extraanatomic bypass grafting to prevent potential neurologic complications when replacing a long segment of the descending aorta. In the second patient, we elected to replace the ascending aorta and the arch to exclude the most severely diseased segment involving the descending aorta and to perform ascending aorta-to-descending aorta bypass grafting, preventing a more extensive operation in an elderly patient.

Generally, aortic aneurysm should be treated by resection and graft replacement, but alternative methods are necessary in some circumstances. In 3 of our patients (patients 10, 12, and 13, Table 3)—1 with unusual primary distal arch aneurysm, 1 with a false aneurysm at a site of a previous graft repair of coarctation, and 1 with a false channel after previous replacement of the descending aorta—the extraanatomic bypass and the exclusion of the diseased segment appeared to be a safer approach than excision and graft replacement.

There are few reports concerning the long-term results of bypass grafting for complex forms of descending aortic disease. Potential long-term complications are graft narrowing with thrombus and neointimal formation, infection, and development of false aneurysms. Our mean follow-up was 2.7 years and extended up to 12 years; although long-term follow-up is pending, none of the patients required reoperation for graft-related complications. Other researchers have reported excellent results for up to 10 years [5, 10]. Spiral computed tomographic scanning has been very helpful in postoperative evaluation and long-term follow-up [6]. Axial reconstruction and multiplanar reformation reveal the full course of the implanted graft (Fig 5).

In summary, no single technique is applicable to patients with these complex problems. However, exposure of the descending aorta through the posterior pericardium in performing ascending aorta-to-descending aorta bypass grafting through a median sternotomy is a safe, flexible method that is particularly useful when simultaneous intracardiac repair is required.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hartzell V. Schaff Charles J. Mullany Richard C. Daly Thomas A. Orszulak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Izhar, U. Articles by Orszulak, T. A. Search for Related Content PubMed PubMed Citation Articles by Izhar, U. Articles by Orszulak, T. A.