Extra-Anatomical Bypass for Repair of Adult Distal Arch Restenosis
The authors present a case of a 20-year-old man with a history of
hypoplastic arch operated on at the age of 13 years old by patch
augmentation through a left thoracotomy. He presented with symptoms of
severe hypertension, requiring a high dose of medications, in addition
to severe fatigue. On examination, there was strong pulsation on the
right radial artery compared with weak pulsation on the left radial and
both femoral arteries. By auscultation, there was systolic murmur
radiated to the back and the gradient was about 40 mm hg. The discussion
of the case with the interventionalist confirmed the difficulty of
stenting and ballooning.
The CT angiogram from
the age of 13 showed severe stenosis between the left common carotid and
left subclavian arteries. The new CT angiogram on the recent
presentation showed restenosis at the same previous area. The echo of
the patient showed mild aortic regurgitation, mild left ventricular
hypertrophy, and trileaflet valve without significant stenosis.
operation, the right radial and left femoral pressure catheters were
applied and showed a gradient of 35 mm hg. The patient underwent a
standard median sternotomy, and cardiopulmonary bypass was instituted by
using an arterial cannula 22 French high in the ascending aorta and 16
French right femoral artery cannula with bicaval cannulae and LA venting
through the right superior pulmonary vein. The authors prefer bicaval
cannulation because this will not compromise the venous return. This
further facilitates exposure of the distal descending thoracic aorta for
construction of the distal anastomosis. Aortic cross-clamp with cold
crystalloid cardioplegic arrest was used to do the distal anastomosis.
The posterior pericardium was opened in a longitudinal fashion over the
descending thoracic aorta just cephalad to the diaphragm, paying
attention to the nearby esophagus, which was identified using a TEE
probe. The distal anastomosis was constructed using a running 4-0
polypropylene suture after the application of a side-biting clamp.
Usually, an 18 mm to 22 mm vascular graft will suffice for most adults
(3). The authors’ graft size was 20 and the length 25 cm. The graft was
then passed posterior to the inferior vena cava on the right side along
the free wall of the right atrium. The proximal anastomosis was
performed in the same manner as the distal anastomosis using a partial
occluding clamp and a running 4-0 polypropylene suture on beating heart.
Ensuring hemostasis of both anstomosis is crucial. Getting off bypass
and decanulation was done without any problems.
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