Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children

Objective: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasi a, can be difficult to manage. Extra-anatomic ascending aorta-descending ao rta bypass grafting through a sternotomy is an alternative approach for thi s problem. Methods: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years ) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The init ial diagnosis was coarctation with hypoplastic arch in 15, interrupted aort ic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interpos ition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian a rterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initi al repair was 8.0 years (range 0.6-18 years). Three children had previous s ternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 wi th simultaneous intracardiac repairs). Results: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were p erformed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gra dient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Thre e children had subsequent successful cardiac operations. Conclusions: Extra-anatomic bypass is an effective and relatively easy appr oach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex a ortic arch reconstruction.