Coarctation of Aorta Repair in an Infant Using Arch to Descending Thoracic Aorta Bypass
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An 11-month-old boy presented with features of congestive cardiac failure. On clinical examination, the lower limb pulses were feeble when compared to the upper limb pulses. The baby was investigated for coarctation of aorta. Echocardiography made the diagnosis of coarctation of aorta, with severe pulmonary arterial hypertension. The patient also had a small atrial septal defect with left to right shunt. Computed tomography (CT) angiogram was performed to delineate the exact anatomy.
The baby was initially stabilized and planned for early coarctation repair. In view of poor collaterals and severe pulmonary arterial hypertension, it was decided to proceed with coarctation resection and end-to-end anastomosis after placing an arch of aorta to the descending thoracic aorta bypass circuit. This bypass circuit prevents the spinal cord ischemia. In this bypass circuit, a pump was not used.
As described in the video, the patient was positioned in the right lateral position after induction with general anaesthesia. A femoral line and a radial arterial line were inserted before positioning to monitor the pressure difference across the coarctation and also to measure the adequacy of repair. Posterolateral thoracotomy was performed. The chest was entered via the fourth intercostal space. The lung was retracted medially, and the mediastinal pleura over the aorta was dissected. The distal arch and proximal descending thoracic aorta (DTA) was mobilized. The left subclavian artery, DTA, and arch of aorta were looped. During dissection, patent ductus arteriosus was present. It was not functional. It was doubly ligated and divided, to aid in mobilization of the aorta.
The next step was cannulation of the arch of aorta and DTA to establish the bypass circuit, after systemic heparinization. Once the arch to DTA bypass was established, the distal perfusion pressure improved to that of the precoarctation pressure. Then the aorta was clamped proximal and distal to the coarctation segment in such a way that the proximal clamp was placed distal to the arch cannulation site, and the distal clamp was placed proximal to the DTA cannulation site. The coarctation segment was resected till the normal portion of the aorta. In this case, the coarctation of the aorta was juxta ductal. After resection, end-to-end anastomosis was performed. Aortic clamps were removed and hemostasis was checked. The bypass circuit was clamped to check the pressure difference between the radial and femoral arterial lines. It was almost equal; this showed the adequacy of repair. Protamine was started and aortic cannulae were removed. Mediastinal pleura was closed over the aorta. The chest was closed in a routine way after placing an intercostal drainage tube.
The patient did well in the postoperative period and is doing well in follow-up.
- Christenson JT, Sierra J, Didier D, Beghetti M, Kalangos A. Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral circulation. Cardiol Young. 2004 Feb;14(1):39-45.