Off-pump ascending aorta or aortic arch to descending aorta bypass with a pericardial roll for the treatment of critically ill infants with interrupted aortic arch

Aim:Standard surgical treatment of the interrupted aortic arch with the use of cardiopulmonary bypass is risky especially in critically ill babies. In this manuscript, we present the results of off-pump pericardial roll bypass for the treatment of aortic interruption.Material and methods:The technique was applied in nine critically ill infants between July 2011 and December 2019. Data were reviewed retrospectively. There were four girls and five boys. The types of the interruption were type B in six cases and type A in three babies. Additional cardiovascular anomalies were ventricular septal defect in all, atrial septal defect or patent foramen ovale in all, single-ventricle pathologies in two and bicuspid aortic valve in three cases. All the patients were in critical situations such as intubated, having symptoms of infection, congestive heart failure or ischaemia and malperfusion leading visceral organ dysfunction.Results:All patients underwent off-pump ascending aorta or aortic arch to descending aorta bypass with a pericardial roll. Post-operative early mortality occurred in one patient with severe mitral regurgitation due to cardio-septic shock. One patient who had single-ventricle pathology underwent bidirectional Glenn and was lost on the post-operative 26th day due to sepsis 2 years after operation. Two patients presented with dilatation of the pericardial tube 18 and 24 months after the operations and one underwent reconstruction of the neo-arch. The remaining patients are asymptomatic, active and within normal limits of body and mental growth.Conclusion:Treatment of interrupted aortic arch with a bypass with an autologous pericardial roll treated with gluteraldehyde without cardiopulmonary bypass seems a safe and reliable technique especially for the treatment of critically ill infants.

Outcomes of aortic coarctation surgical repair in adolescents and adults

OBJECTIVES Coarctation of the aorta (CoA) in adolescents and adults is relatively rare. Several operative techniques have been reported, but there is no consensus. METHODS From November 1994 to July 2018, a total of 24 adolescents and adults underwent CoA repair. The mean age at operation was 29.9 ± 15.1; 19 (79%) patients were older than 18. Sixteen (67%) patients had arterial hypertension, 5 (21%) patients had bicuspid aortic valve, 4 (17%) patients had descending aneurysm, 2 (8%) patients had ascending aneurysm, 2 (8%) patients had patent ductus arteriosus and 1 (4%) patient had atrial septal defect. Three patients had prior surgery (2 CoA repair, 1 ventricular septal defect repair). RESULTS Surgical corrections included extra-anatomical bypasses in 12 (50%) patients (9: left subclavian artery to descending aorta bypass, 2 proximal-to-distal coarctation bypasses, 1 ascending-to-descending aortic bypass), end-to-end anastomosis in 6 (25%) patients, resections and interpositions of a tube graft in 5 (21%) patients and arch augmentation with a tube graft in 1 (4%) patient. The mean follow-up duration was 6.2 ± 5.1 years. No mortality was observed. No patient required reoperation or reintervention. The mean upper extremity systolic pressure significantly decreased from 142.4 ± 30.3 mmHg preoperatively to 121.1 ± 15.9 mmHg postoperatively (P = 0.002). Arterial pressure gradient between upper and lower extremities significantly decreased from 50.0 ± 21.8 mmHg preoperatively to 9.7 ± 13.5 mmHg postoperatively (P < 0.001). Among patients undergoing left subclavian artery to descending aorta bypass, 8 patients underwent ankle brachial pressure index evaluation. Postoperative mean right- and left-sided ankle brachial pressure index were 0.96 ± 0.16 and 0.94 ± 0.11, respectively. All grafts were patent at the last follow-up. CONCLUSIONS CoA repair in adolescents and adults showed good outcomes. Left subclavian artery to descending aorta bypass grafting is safe and effective for managing CoA in adolescents and adults.

Management of cervical aortic arch complicated by multiple aneurysms

OBJECTIVES Cervical aortic arch with aneurysm formation is considered an extremely rare condition. Here, we summarize our experience in treating 8 patients. We validated extra-anatomic ascending-to-infrarenal abdominal aorta bypass through the retroperitoneal cavity without circulatory arrest as an alternative treatment for patients with a tortuous arch that was unsuitable for endovascular repair. METHODS From March 2015 to April 2018, 8 patients (7 women; median age 46 years) diagnosed with cervical aortic arch complicated with aneurysm formation were treated at Peking Union Medical College Hospital and the Affiliated Hospital of Qingdao University. After assessment of the anatomical characteristics, 4 patients underwent endovascular repair. Three patients with a tortuous aortic arch and saccular aneurysm formation between the left common carotid artery and the left subclavian artery were treated with an extra-anatomic ascending-to-infrarenal abdominal aorta bypass and aneurysm indwelling. One patient refused surgical intervention and is being followed up on a yearly basis at our outpatient clinic. No circulatory arrest was required during surgery. RESULTS No severe postoperative complications were observed during follow-up (6–36 months). Postoperative computed tomography angiography revealed patent blood flow in the prosthetic aortic graft bypass. No endoleak, migration or stenosis of the stent grafts was observed in patients following endovascular repair. The left subclavian artery was preserved in 3 patients. Follow-up computed tomography angiography revealed satisfactory postoperative results in all patients, with no signs of aortic dilation or coarctation. CONCLUSIONS Ascending-to-infrarenal abdominal aorta bypass through the retroperitoneal cavity is a safe and effective treatment for cervical aortic arch with a tortuous aorta complicated by aneurysm formation and coarctation.

Adolescent coarctation of aorta treated with subclavian-descending aorta bypass grafting

BackgroundAortic coarctation in older children most frequently represents cases of re-coarctation following previous transcatheter or surgical therapy or missed cases of native coarctation.MethodsWe describe three cases of adolescents – two girls and one boy – with aortic coarctation, operated between January, 2012 and December, 2013. Computed tomography angiography was performed as an essential diagnostic procedure.ResultsHypertension was detected, and weaker arterial pulses in the lower limbs were noted in all cases. All operations were performed via left posterolateral thoracotomy. Aortic coarctation was treated surgically, with left subclavian-lower descending thoracic aorta bypass grafting. Postoperative course was uneventful in all cases. No residual brachial-ankle pressure gradient was observed, and all patients have remained in good condition after the operation.ConclusionsSurgical treatment of aortic coarctation in adolescent patients can be achieved by resection with end-to-end anastomosis, interposition of a graft or bypass graft across the area of coarctation when the distance to be bridged is too long for end-to-end repair.The extra-anatomic subclavian-descending aortic bypass grafting provides good results in adolescent patients, particularly in those with complex coarctation.