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• W2283177579 abstract "Central MessageSafe treatment of late complications after coarctation repair requires tailoring open, hybrid, or endovascular techniques to the patient, considering comorbidities, anatomy, morphology, and experience.See Article page 1760. Safe treatment of late complications after coarctation repair requires tailoring open, hybrid, or endovascular techniques to the patient, considering comorbidities, anatomy, morphology, and experience. See Article page 1760. Despite improvements in survival due to early detection and better medicine, many late survivors after repair of aortic coarctation will develop complications, including recurrent coarctation, aneurysms, or pseudoaneurysms in the treated segment.1Brown M.L. Burkhart H.M. Connolly H.M. Dearani J.A. Hagler D.J. Schaff H.V. Late outcomes of reintervention on the descending aorta after repair of aortic coarctation.Circulation. 2010; 122: 81-84Crossref PubMed Scopus (44) Google Scholar In a review of 110 adolescents and adults undergoing open, hybrid, or endovascular repair at the Cleveland Clinic, we found the mean age at intervention was 38 years and most reoperations occurred more than 2 decades after initial repair.2Roselli E.E. Qureshi A. Idrees J. Lima B. Greenberg R.K. Svensson L.G. et al.Ann Thorac Surg. 2012; 94: 751-758Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar These adults with congenital aortic disease require optimal medical therapy and lifelong surveillance with intermittent cross-sectional imaging to screen for late complications. When they reach a threshold where reintervention is indicated, they do well with repair when performed at a high-volume aortic center. Cabasa and colleagues3Cabasa A.S. Bower T.C. Pochettino A.B. Arch reconstruction after a previous ascending-to-descending aortic bypass for coarctation of the aorta.J Thorac Cardiovasc Surg. 2016; 151: 1760-1763Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar describe an excellent outcome in a 47-year-old patient after a third-time operation at their high-volume tertiary center, with experience caring for complex thoracic aortic disease, 36 years after his last operation. The patient described in this well-done report and accompanying video developed a 6-cm pseudoaneurysm at the site of a previous aorta bypass. Indication to reoperate was undeniable given the large size and the patient's age. With pseudoaneurysm or saccular aneurysms after previous coarctation repair, I often recommend repair even sooner given their less predictable nature. Preoperative computed tomography demonstrated a lobulated shape consistent with the complex morphology of this disease. It is not surprising to see that this patient developed this complication. The old graft looked rather small for a well-developed adult male and may have become scarred down over approximately 4 decades. Tissue that the bypass was sewn to was proximal on the descending aorta and probably not great quality. We have also seen late degeneration of these grafts over a long period of time and have even described aneurysm of a knitted graft used the same way: passing across the pulmonary trunk from ascending to descending.4Kalahasti V. Roselli E.E. Flamm S.D. Krasuski R.A. Aneurysmal ascending to descending aorta bypass graft compressing the pulmonary artery.Interact Cardiovasc Thorac Surg. 2009; 9: 730-732Crossref Scopus (1) Google Scholar Nonetheless, use of aortic bypass is typically durable for treating coarctation. When doing so, we choose an 18- to 20-mm graft and prefer retrocaval positioning to the anterior lie for performing this repair. Although very helpful for late or recurrent coarctation, bypass will not satisfactorily address aneurysm without additional intervention. Several approaches, including endovascular and hybrid techniques, may be applied to these patients.2Roselli E.E. Qureshi A. Idrees J. Lima B. Greenberg R.K. Svensson L.G. et al.Ann Thorac Surg. 2012; 94: 751-758Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 5Idrees J. Roselli E.E. Blackstone E.H. Clair D. Svensson L.G. Hybrid repair of aortic aneurysm in patients with previous coarctation.J Thorac Cardiovasc Surg. 2014; 148: 60-64Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Selecting the best approach for each patient requires careful consideration of several factors. First, we consider comorbid cardiovascular disease and the need for concomitant procedures. For example, if the patient has severe stenosis of a bicuspid aortic valve, then we choose an open or hybrid approach through a partial or full sternotomy that allows for cardiac arrest and valve replacement. This patient had normal cardiac and valvular function, and coronary angiography. Next, we consider morphology of the aneurysm itself and the condition of the arch disease. The length of aorta involved with aneurysm in this patient is short, and the descending aorta beyond the disease is normal appearing. This suggests that a single-stage repair will suffice, and a 2-stage elephant trunk procedure is not necessary. Close inspection of the arch is required to determine the potential for a purely endovascular repair. This patient's coarctation was very proximal, involving the origin of the left subclavian and the left common carotid artery, leaving no adequate landing zone for a safe endovascular repair. A hybrid reconstruction involving partial sternotomy and direct device delivery through the coarctation with patch reconstruction of the hypoplastic segment would have been feasible and may have limited the need for distal exposure and manipulation of the recurrent laryngeal nerve, but it is still a rather invasive operation dependent on surgical experience with these techniques.5Idrees J. Roselli E.E. Blackstone E.H. Clair D. Svensson L.G. Hybrid repair of aortic aneurysm in patients with previous coarctation.J Thorac Cardiovasc Surg. 2014; 148: 60-64Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Instead, the authors chose a trapdoor incision to resect all of the involved segments, perform an anatomic reconstruction using modern techniques for brain protection, and create a direct bypass to the left subclavian artery. This technique was more invasive and complicated by left recurrent laryngeal nerve palsy, but it was well tolerated, and the patient recovered well with what appears to be a very functional and, hopefully, durable anatomic result. They chose the shoe that fit, based on what they found, and are to be congratulated on a good result. Arch reconstruction after a previous ascending-to-descending aortic bypass for coarctation of the aortaThe Journal of Thoracic and Cardiovascular SurgeryVol. 151Issue 6PreviewIf left untreated, coarctation of the aorta may lead to early mortality.1,2 Several reparative techniques have been described for “complex coarctation,” including the extra-anatomic aortic bypass.1,2 However, initial repairs are often complicated by prosthetic graft infection, recoarctation, and pseudoaneurysm formation, requiring reintervention.3-5 Because of the complexity of the second operation, the approach has always led to discussion among experts.1 We present a surgical management for an anastomotic pseudoaneurysm after a previous ascending-to-descending aortic bypass. Full-Text PDF Open Archive" @default.
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• W2283177579 title "If the shoe fits, choose it: Tailored strategy for postcoarctation complications" @default.
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