Management of re-coarctation due to prosthetic graft pseudo-intimal dissection
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《血管的通路杂志》
Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Edgbaston, Birmingham, B15 2TH, UK
Abstract
Re-coarctation is a recognised late complication of surgical coarctation repair. Re-operation in these patients is difficult and the role of surgery has been partly subsumed by balloon angioplasty and endovascular stenting. We describe a patient who twice developed re-coarctation, the second time because of a raised pseudo-intimal flap within an interposition graft. It was managed successfully with an ascending–descending aorta extra-anatomic graft.
Key Words: Arteries; Coarctation; Prosthesis
1. Introduction
Despite the overall satisfactory outcome of the surgical repair of coarctation, there remains 5–30% incidence of re-coarctation requiring re-intervention [1]. Although endovascular management is used increasingly [2], open intervention remains necessary in some cases. The surgical technique for re-operation depends on the type of initial repair, length of aortic narrowing, the proximity to the aortic arch, the patient's age and concomitant cardiac disease. Various anatomical and extra-anatomical bypass techniques using prosthetic grafts have been described [3,4].
Non-anastomotic narrowing of the prosthetic graft is uncommon. We describe a case that twice developed re-coarctation due to occlusion of prosthetic grafts.
2. Case details
A 58-year-old female presented with pulmonary oedema. On examination, she had upper–lower limb systolic pressure gradient of 90 mmHg. At the age of eight, she had undergone her first coarctation repair using an interposition Orlon graft (Orlon, an additional polymer of acrylonitrile, was the first prosthetic graft manufactured as seamless tube). At age 33, she was re-investigated for hypertension and re-coarctation was confirmed on aortography. At the second procedure, the Orlon graft was found to be calcified and an extra-anatomic 14 mm dacron graft was interposed between the left subclavian artery and mid-descending thoracic aorta. During the current admission, invasive imaging confirmed a gradient of 70 mmHg and a CT scan demonstrated partial occlusion of the extra-anatomic bypass graft at the junction of proximal and mid third, extending for 4 cm distally. This appeared to be due to a dissecting flap of a pseudointima in the graft. The ascending aorta, arch and distal descending aorta were of normal calibre. The original Orlon graft was completely occluded and partly calcified. The distal descending thoracic aorta was, however, patent. The MRI angiogram confirmed these findings (Fig. 1).
Percutaneous intervention was felt inadvisable in view of the occluded first graft and a raised flap in the second. Therefore, an extra-anatomic ascending–descending aorta conduit, using a 20-mm gelweave gelatine-impregnated polyester graft (Vascutek, Renfrewshire, UK) was constructed via a median sternotomy utilising cardiopulmonary bypass. Access to posterior pericardium and descending aorta was difficult, due to severe left ventricular hypertrophy and therefore, the descending aorta anastomosis was performed during a period of cardioplegic arrest and left atrial venting. The conduit was routed posterior to the inferior vena cava and anastomosed to the ascending aorta using a partial occlusion clamp. The patient made an uneventful postoperative recovery with no upper:lower limb pressure gradient remaining. An MRI examination at three months demonstrated satisfactory graft location (Fig. 2).
3. Discussion
This case is of interest due to the repeated presentations of re-coarctation as a result of obstruction within prosthetic grafts. In the first instance it presumably was the result of the calcific degeneration of relatively small prosthetic graft. On the second occasion, the obstruction was due to spontaneous dissection of a pseudointima within a dacron graft. There are very few reported cases of this phenomenon. Application of vascular clamps on a knitted dacron graft has resulted in dissection of pseudointima and subsequent occlusion [5] and a shunt graft interposed between the main pulmonary artery and descending aorta in a patient with congenital heart disease has been found to be dissected and obstructed at autopsy [6].
An interposition graft between left subclavian artery and descending aorta as used in this patient for the first re-coarctation operation has been described with good long-term results [4]. This technique avoids extensive dissection and total cross clamping of the aorta. However, if this or similar methods fail, the extra-anatomic ascending–descending aortic conduit would appear to be the technique of choice [3,7]. The use of extra-anatomic graft interposition was first described in 1980 [8]. The advantages include access to the descending thoracic aorta above the diaphragm in a segment with less collateral circulation, avoids manipulation of a coarctation segment in which the aortic wall has structural alterations and extensive collateral circulation, especially in adults. The use of an ascending–descending aortic conduit avoids possible complications of repeat thoracotomy including extensive dissection, bleeding, parenchymal lung injury, recurrent laryngeal or phrenic nerve injury, chylothorax and spinal cord ischaemia [3]. It also avoids hypothermic circulatory arrest in the repair of aortic arch coarctation and other cardiac pathology can be repaired simultaneously through sternotomy. On occasion, it can also be performed without cardiopulmonary bypass [9].
4. Conclusion
This report describes an unusual case of prosthetic graft obstruction resulting in recurrent coarctation and its successful management. No single surgical or endovascular procedure is applicable in all the re-coarctation cases and a multi-disciplinary decision-making process is advisable in the management of such patients.
References
Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation 1989; 80:840–845.
Chessa M, Carrozza M, Butera G, Piazza L, Negura DG, Bussadori C, Bossone E, Giamberti A, Carminati M. Results and mid-long-term follow-up of stent implantation for native and recurrent coarctation of the aorta. Eur Heart J 2005; 26:2728–2732.
Izhar U, Schaff HV, Mullany CJ, Daly RC, Orszulak TA. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000; 70:31–37.
Elkerdany A, Hassouna A, Elsayegh T, Azab S, Bassiouni M. Left subclavian-aortic bypass grafting in primary isolated adult coarctation. Cardiovasc Surg 1999; 7:351–354.
Shigematsu K, Shigematsu H, Nishikage S, Origuchi N, Ishikawa I, Furuta Y. Non-anastomotic midgraft stenosis of a knitted Dacron graft after arterial reconstruction. Report of a case. Int Angiol 2001; 20:248–250.
Ohuchi H, Nagata N, Okabe H, Koseni K, Itoh K. Dissection of the pseudointima followed by lethal obstruction of the prosthetic graft – a case report. Nippon-Kyobu-Geka-Gakkai-Zasshi 1995; 43:1963–1966.
Arakelyan V, Spiridonov A, Bockeria L. Ascending-to-descending aortic bypass via right thoracotomy for complex (re-) coarctation and hypoplastic aortic arch. Eur J Cardiothorac Surg 2005; 27:815–820.
Vijayanagar R, Natarajan P, Eckstein PF, Bognolo DA, Toole JC. Aortic valvular insufficiency and postductal aortic coarctation in the adult. Combined surgical management through median sternotomy: a new surgical approach. J Thorac Cardiovasc Surg 1980; 79:266–268.
Kanter KR, Erez E, Williams WH, Tam VK. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg 2000; 120:885–890.(Maninder S. Kalkat, Sara A. Thorne, Pete)
Abstract
Re-coarctation is a recognised late complication of surgical coarctation repair. Re-operation in these patients is difficult and the role of surgery has been partly subsumed by balloon angioplasty and endovascular stenting. We describe a patient who twice developed re-coarctation, the second time because of a raised pseudo-intimal flap within an interposition graft. It was managed successfully with an ascending–descending aorta extra-anatomic graft.
Key Words: Arteries; Coarctation; Prosthesis
1. Introduction
Despite the overall satisfactory outcome of the surgical repair of coarctation, there remains 5–30% incidence of re-coarctation requiring re-intervention [1]. Although endovascular management is used increasingly [2], open intervention remains necessary in some cases. The surgical technique for re-operation depends on the type of initial repair, length of aortic narrowing, the proximity to the aortic arch, the patient's age and concomitant cardiac disease. Various anatomical and extra-anatomical bypass techniques using prosthetic grafts have been described [3,4].
Non-anastomotic narrowing of the prosthetic graft is uncommon. We describe a case that twice developed re-coarctation due to occlusion of prosthetic grafts.
2. Case details
A 58-year-old female presented with pulmonary oedema. On examination, she had upper–lower limb systolic pressure gradient of 90 mmHg. At the age of eight, she had undergone her first coarctation repair using an interposition Orlon graft (Orlon, an additional polymer of acrylonitrile, was the first prosthetic graft manufactured as seamless tube). At age 33, she was re-investigated for hypertension and re-coarctation was confirmed on aortography. At the second procedure, the Orlon graft was found to be calcified and an extra-anatomic 14 mm dacron graft was interposed between the left subclavian artery and mid-descending thoracic aorta. During the current admission, invasive imaging confirmed a gradient of 70 mmHg and a CT scan demonstrated partial occlusion of the extra-anatomic bypass graft at the junction of proximal and mid third, extending for 4 cm distally. This appeared to be due to a dissecting flap of a pseudointima in the graft. The ascending aorta, arch and distal descending aorta were of normal calibre. The original Orlon graft was completely occluded and partly calcified. The distal descending thoracic aorta was, however, patent. The MRI angiogram confirmed these findings (Fig. 1).
Percutaneous intervention was felt inadvisable in view of the occluded first graft and a raised flap in the second. Therefore, an extra-anatomic ascending–descending aorta conduit, using a 20-mm gelweave gelatine-impregnated polyester graft (Vascutek, Renfrewshire, UK) was constructed via a median sternotomy utilising cardiopulmonary bypass. Access to posterior pericardium and descending aorta was difficult, due to severe left ventricular hypertrophy and therefore, the descending aorta anastomosis was performed during a period of cardioplegic arrest and left atrial venting. The conduit was routed posterior to the inferior vena cava and anastomosed to the ascending aorta using a partial occlusion clamp. The patient made an uneventful postoperative recovery with no upper:lower limb pressure gradient remaining. An MRI examination at three months demonstrated satisfactory graft location (Fig. 2).
3. Discussion
This case is of interest due to the repeated presentations of re-coarctation as a result of obstruction within prosthetic grafts. In the first instance it presumably was the result of the calcific degeneration of relatively small prosthetic graft. On the second occasion, the obstruction was due to spontaneous dissection of a pseudointima within a dacron graft. There are very few reported cases of this phenomenon. Application of vascular clamps on a knitted dacron graft has resulted in dissection of pseudointima and subsequent occlusion [5] and a shunt graft interposed between the main pulmonary artery and descending aorta in a patient with congenital heart disease has been found to be dissected and obstructed at autopsy [6].
An interposition graft between left subclavian artery and descending aorta as used in this patient for the first re-coarctation operation has been described with good long-term results [4]. This technique avoids extensive dissection and total cross clamping of the aorta. However, if this or similar methods fail, the extra-anatomic ascending–descending aortic conduit would appear to be the technique of choice [3,7]. The use of extra-anatomic graft interposition was first described in 1980 [8]. The advantages include access to the descending thoracic aorta above the diaphragm in a segment with less collateral circulation, avoids manipulation of a coarctation segment in which the aortic wall has structural alterations and extensive collateral circulation, especially in adults. The use of an ascending–descending aortic conduit avoids possible complications of repeat thoracotomy including extensive dissection, bleeding, parenchymal lung injury, recurrent laryngeal or phrenic nerve injury, chylothorax and spinal cord ischaemia [3]. It also avoids hypothermic circulatory arrest in the repair of aortic arch coarctation and other cardiac pathology can be repaired simultaneously through sternotomy. On occasion, it can also be performed without cardiopulmonary bypass [9].
4. Conclusion
This report describes an unusual case of prosthetic graft obstruction resulting in recurrent coarctation and its successful management. No single surgical or endovascular procedure is applicable in all the re-coarctation cases and a multi-disciplinary decision-making process is advisable in the management of such patients.
References
Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation 1989; 80:840–845.
Chessa M, Carrozza M, Butera G, Piazza L, Negura DG, Bussadori C, Bossone E, Giamberti A, Carminati M. Results and mid-long-term follow-up of stent implantation for native and recurrent coarctation of the aorta. Eur Heart J 2005; 26:2728–2732.
Izhar U, Schaff HV, Mullany CJ, Daly RC, Orszulak TA. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg 2000; 70:31–37.
Elkerdany A, Hassouna A, Elsayegh T, Azab S, Bassiouni M. Left subclavian-aortic bypass grafting in primary isolated adult coarctation. Cardiovasc Surg 1999; 7:351–354.
Shigematsu K, Shigematsu H, Nishikage S, Origuchi N, Ishikawa I, Furuta Y. Non-anastomotic midgraft stenosis of a knitted Dacron graft after arterial reconstruction. Report of a case. Int Angiol 2001; 20:248–250.
Ohuchi H, Nagata N, Okabe H, Koseni K, Itoh K. Dissection of the pseudointima followed by lethal obstruction of the prosthetic graft – a case report. Nippon-Kyobu-Geka-Gakkai-Zasshi 1995; 43:1963–1966.
Arakelyan V, Spiridonov A, Bockeria L. Ascending-to-descending aortic bypass via right thoracotomy for complex (re-) coarctation and hypoplastic aortic arch. Eur J Cardiothorac Surg 2005; 27:815–820.
Vijayanagar R, Natarajan P, Eckstein PF, Bognolo DA, Toole JC. Aortic valvular insufficiency and postductal aortic coarctation in the adult. Combined surgical management through median sternotomy: a new surgical approach. J Thorac Cardiovasc Surg 1980; 79:266–268.
Kanter KR, Erez E, Williams WH, Tam VK. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg 2000; 120:885–890.(Maninder S. Kalkat, Sara A. Thorne, Pete)