Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation

Objective: Operation for aortic recoarctation and/or residual hypoplastic a rch represents a surgical challenge because of surrounding scar tissue in t he coarctation area, hazard of spinal cord ischemia due to aortic cross-cla mping, laceration of the recurrent nerve, and the choice of the best approa ch. We demonstrate the first results of an anatomically guided technique vi a the prior left thoracotomy approach without establishment of cardiopulmon ary bypass. Methods: Since 1989, five patients underwent anatomically posit ioned ascending-descending bypass grafting for treatment of recoarctation. Indication was a non-dilatable hypoplastic aortic arch segment; in two case s an additional isthmic restenosis was present. Inclusion criteria for our technique was an aorta ascending diameter large enough to allow partial cla mping. Primary repair of aortic coarctation was end-to-end anastomosis in f our patients and patch angioplasty in one. Mean age at primary repair was 5 .5 years and at reoperation 16.1 years. Systolic pressure gradients at rest ranged from 35 to 70 mmHg; upper extremity hypertension was present in all patients. Operative technique consisted of performing a dacron or PTFE aor ta ascending-descending bypass graft parallel to the aortic arch, size 18 o r 20 mm in diameter, via the prior left thoracotomy. Results: There were no intraoperative complications and all patients survived. Postoperative comp lications were left lung atelectasis with necessity of reintubation, perica rdial effusion, and transient left diaphragm elevation, each in one patient . After 7-90 months all patients are free of symptoms, have normal blood pr essure (with two patients being under anti-hypertensive medication), and ha ve no echocardiographically measurable pressure gradients. Conclusions: Ana tomically positioned aorta ascending-descending bypass grafting via the pri or left posterolateral thoracotomy without cardiopulmonary bypass is a safe and efficient method for operation of complex recoarctation in patients wi th an acceptable size of the aorta ascendens. (C) 1999 Elsevier Science B.V . All rights reserved.