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Ann Thorac Surg 2001;72:1222-1224
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Reoperation and coarctation of the aorta: the need for lifelong surveillance

^a The New Children’s Hospital, Sydney, New South Wales, Australia

Accepted for publication June 11, 2001.

Address reprint requests to Dr Manganas, Department of Cardiothoracic Surgery, Prince of Wales Hospital, Barker St, Randwick, NSW, Australia 2031
e-mail: conmanganas{at}hotmail.com

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We report a series of reoperations in 23 patients who had undergone previous aortic coarctation repair.

Methods. The medical records of these patients were reviewed, and the patients were followed up by telephone interview. Mean age at reoperation was 25 years. There was a mean of 18 years between initial coarctation repair and reoperation. Indications for reoperation included recoarctation (9 patients), aortic aneurysm (8), aortobronchial fistulas with exsanguinating hemorrhage (2), subaortic stenosis (1), ruptured thoracic aneurysm (1), ruptured sinus of Valsalva aneurysm (1), and supramitral stenosing ring (1).

Results. There were no specific intraoperative complications. Three patients required reexploration for bleeding. An acutely ischemic lower limb developed in 1 patient secondary to a common femoral artery embolus, which necessitated embolectomy.

Conclusions. Reoperation for postcoarctation repair patients can be performed with good results. Sudden life-threatening hemorrhage due to aortobronchial fistulas in patients having undergone Dacron patch aortoplasty, as well as long-term obstructive phenomena seen anywhere along the left ventricular outflow tract, make lifelong surveillance of these patients mandatory.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The evolution of surgery for coarctation of the aorta has been well documented since the first described successful repair by Crafoord and Nylin [1] in Sweden in 1944. Vorsschuldte [2] described the technique of prosthetic patch aortoplasty in 1957, and Waldhausen and Nahrwold [3] described the technique of subclavian flap aortoplasty in infants in 1966. Problems with these techniques have included a significant incidence of aneurysm formation with Dacron (C. R. Bard, Haverhill, PA) patch aortoplasty [4], and an unacceptably high recoarctation rate with the subclavian flap aortoplasty [5]. The technique of extended end-to-end anastomosis appears to give good short-term to intermediate-term results with a low complication rate and has gained in popularity as the technique of choice when repairing coarctations of the aorta [6, 7].

Unfortunately, no technique of repair is completely free of complications requiring reoperation. We report a series of 23 patients who underwent reoperation after having had coarctation repair as children.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between 1982 and 1999, 23 patients who underwent coarctation repair as children or adolescents underwent reoperation for various disorders occurring along the left ventricular outflow tract. There were 13 men and 10 women in this series. The mean age at reoperation was 25 years (range 16 to 52). Mean time between initial coarctation repair and reoperation was 18 years (range 10 to 28). Patients whose medical records indicated an initial operation involving a hypoplastic arch, "aortitis," or those having other multiple congenital heart defects corrected with the coarctation were excluded from this series.

During this period, there were 580 documented cases of coarctation having been corrected, with three surgeons involved. Follow-up was obtained for 383 patients. In all, 23 patients required operation after coarctation repair. Complete follow-up on all patients who had undergone coarctation repair was not possible.

Indications for reoperation included the following: recoarctation (9 cases) in which symptoms referable to the recoarctation or a gradient of greater than 20 mm Hg were identified; progressive aneurysmal dilatation of the aortic arch or ascending or descending thoracic aorta (8 cases) as determined by size greater than 5 to 6 cm on CT or MRI scans; aortobronchial fistulas presenting with massive hemoptysis (2 cases); subaortic stenosis (1 case); and supramitral stenosing ring, aortic stenosis, and ruptured sinus of Valsalva aneurysm (1 case each) (Table 1).

Operative details
Patients with recoarctations underwent redo left thoracotomy with standard adhesion lysis, and depending on surgical preference underwent redo Dacron patch aortoplasty (4 cases), interposition tube grafting (4 cases), or resection with end-to-end anastomosis (1 case). Systemic heparinization was not used in all cases but when used, a dose of 1 mg/kg was employed before aortic clamps were applied. Spinal cord protection was achieved using left atrial to left femoral artery bypass when interposition tube grafting was performed, aiming to perfuse the distal arterial limb at a mean pressure of at least 60 mm Hg.

Surgery for aneurysms of the ascending aorta and proximal arch was performed through a median sternotomy using standard cardiopulmonary bypass, cooling, cardioplegia, and periods of deep hypothermic circulatory arrest when necessary. Retrograde cerebral perfusion through the superior vena cava is not a routine technique employed at our institution. Packing the head in ice and systemic cooling to 18°C is the preference for cerebral protection.

One patient who presented with massive hemoptysis secondary to an aortobronchial fistula had initially undergone an end-to-end resection and reanastomosis at 3 years of age. She underwent reoperation at age 9 for recoarctation with Dacron patch aortoplasty, and a further operation at age 24 years for recoarction. This procedure involved an aortic arch to descending thoracic aorta bypass with a tailored Dacron tube graft; torrential hemorrhage developed from her distal anastomosis at age 29. This patient required emergency institution of femorofemoral bypass, cooling, and hypothermic circulatory arrest in order to control exsanguinating hemorrhage from the distal anastomotic site of the bypass graft.

Generally, prosthetic grafts were separated from lung tissue by closure of the pleura where possible to reduce the risk of aortobronchial fistula formation. Intercostal drainage and chest closure were routinely performed and antibiotic prophylaxis administered.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There were no specific intraoperative complications and no operative deaths in this series. Specifically, there was no paraplegia, no nerve damage, no chylothoraces, and no cases of stroke or myocardial infarction. Two patients required reexploration for bleeding, with adult respiratory distress syndrome developing in 1 of these patients that required prolonged support in the intensive care unit. Both these patients were subsequently well at follow-up.

In 1 patient undergoing repair of a descending thoracic aneurysm with a tube interposition graft, an acutely ischemic limb developed secondary to a common femoral embolus and required embolectomy. A compartment syndrome necessitating fasciotomy subsequently developed. This patient was well at follow-up 6 months postoperatively. One patient with ruptured sinus of Valsalva aneurysm and cardiogenic shock required temporary dialysis postoperatively; he remains well at follow-up.

One patient died 2 years after reoperation for recoarctation successfully treated by redo Dacron patch aortoplasty. He was known to have a bicuspid aortic valve, and a fulminant infective endocarditis developed necessitating urgent aortic and mitral valve replacements. Large intracerebral hemorrhage and multiorgan failure developed secondary to acute bacterial endocarditis in this patient. After a mean follow-up of 59 months (range 2 to 208), all 22 surviving patients are asymptomatic with respect to the conditions that led to their reoperation.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This series demonstrates that excellent surgical results can be obtained in this technically challenging group of patients needing postcoarctation repair.

A recent report by Daebritz and colleagues [8] suggests that extra-anatomic ascending-to-descending thoracic aorta bypass through a left thoracotomy for recoarctation is an alternative to end-to-end anastomosis, redo Dacron patch aortoplasty, or repair with end-to-end interposition tube graft. However, we would caution against using the technique of extra-anatomic bypass with a distal end-to-side anastomosis, given that we were confronted with a patient presenting with exsanguinating hemorrhage from an aortobronchial fistula occurring at the distal end-to-side extra-anatomic bypass.

Aortobronchial fistulas can present with catastrophic bleeding and will probably require emergency femorofemoral bypass, cooling, and circulatory arrest to control the bleeding and repair the fistula. The two cases of aortobronchial fistulas with massive hemoptysis in our series occurred as a result of false aneurysm erosion into the bronchial tree and were treated by this method. Rigid bronchoscopy, once bypass was instituted, was then used to aspirate blood from the bronchial tree.

Dacron patch aortoplasty has been associated with late aneurysm formation according to reports by Hehrlein and associates [4], with presentations up to 20 years after initial surgery. Resection of the intimal ridge in a coarcted segment is said to expose the posterior aortic wall to abnormal stresses thus leading to the classic aneurysm "opposite the patch" [4, 9]. Reports of late aneurysm formation post-Dacron patch aortoplasty range from 5% to 38% of cases of patch aortoplasty [10]. In our series, 6 of the 14 patients who underwent Dacron patch aortoplasty developed thoracic aortic aneurysms. Aneurysms of the thoracic aorta opposite the patch developed in 4 patients, and aneurysms of the thoracic aorta developed elsewhere in 2 patients. Aortobronchial fistulas secondary to thoracic aortic false aneurysms developed in 2 patients. We therefore caution against the use of Dacron patch aortoplasty as a primary or reoperative surgical technique in the treatment of coarctation.

We observed complications of fistulas, aneurysm formation, recoarctation, and obstructive phenomena along the left ventricular outflow tract regardless of the initial technique of coarctation repair. No single technique is free of complications. However, our preferred method of treatment of coarctation is resection with end-to-end anastomosis for primary operation and interposition tube graft with end-to-end anastomosis for recoarctation.

Although cases of progressive aneurysmal dilatation can be followed up serially over time with CT or MRI scanning, and surgery offered on an elective basis, emergency presentations will occasionally occur, especially in patients who have undergone coarctation repair with Dacron patch aortoplasty in childhood and are subsequently lost to follow-up. Reoperation for postcoarctation repair patients can be performed with low morbidity and mortality. The problem of sudden life-threatening hemorrhage due to aortobronchial fistulas in patients who have undergone Dacron patch aortoplasty, as well as the spectrum of long-term obstructive phenomena seen anywhere along the left ventricular outflow tract, make lifelong surveillance of these patients mandatory.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Crafoord C., Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:347-361.
2. Vorsschuldte K. Surgical correction of the aorta by an "isthmus plastic" operation. Thorax 1961;16:338.
3. Waldhausen J.A., Nahrwold D.L. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532-533.[Medline]
4. Hehrlein F.W., Mulch J., Rautenburg H.W., Schlepper M., Scheld H.H. Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92:226-230.[Abstract]
5. Sanchez G.R., Balsara R.K., Dunn J.M., Mehta A.V., O’Riordan A.C. Recurrent obstruction after subclavian flap repair of coarctation of the aorta in infants. Can it be predicted or prevented?. J Thorac Cardiovasc Surg 1986;91:738-746.[Abstract]
6. Presbitero P., Demarie D., Villani M., et al. Long term results (15–30 years) of surgical repair of aortic coarctation. Br Heart J 1987;57:462-467.[Abstract/Free Full Text]
7. van Heurn L.W., Wong C.M., Spiegelhalter D.J., et al. Surgical treatment of aortic coarctation in infants younger than three months: 1985 to 1990. Success of extended end-to-end arch aortoplasty. J Thorac Cardiovasc Surg 1994;107:74-85.[Abstract/Free Full Text]
8. Daebritz S., Fausten B., Sachweh J., Muhler E., Franke A., Messmer B.J. Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999;16:519-523.[Abstract/Free Full Text]
9. Bergdahl L., Ljungqvist A. Long-term results after repair of coarctation of the aorta by patch grafting. J Thorac Cardiovasc Surg 1980;80:177-181.[Abstract]
10. Kron I.L., Flanagan T.L., Rheuban K.S., et al. Incidence and risk of reintervention after coarctation repair. Ann Thorac Surg 1990;49:920-925.[Abstract]

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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): Richard B. Chard Graham R. Nunn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Manganas, C. Articles by Nunn, G. R. Search for Related Content PubMed PubMed Citation Articles by Manganas, C. Articles by Nunn, G. R. Related Collections Great vessels