Adult coarctation of aorta with postcoarct dissecting aortic aneurysm successfully repaired under circulatory arrest

Abstract

A 41-year-old physical trainer was detected to have type III aortic dissection while being evaluated for left-side chest pain and hypertension of 5 months' duration. On medications (atenelol 50 mg once daily and hydrochlorothiazide 25 mg twice daily), hypertension was controlled to 160/80 mm Hg with lower limb blood pressure of 110 mm Hg. Computed tomography angiogram revealed classic postsubclavian coarctation of aorta, double-barreled aorta in the postcoarct segment, and an intimal flap involving thoracic and abdominal aorta up to the origin of the superior mesenteric artery (A/Cover). He underwent repair of the twin lesions (B) of the thoracic aorta using a 24-mm coated polyester vascular graft (Albograft; Edwards Life Sciences SA, Nyon, Switzerland) under cardiopulmonary bypass (CPB) and total circulatory arrest. CPB was achieved using bifurcated arterial return to the right axillary and left femoral arteries, and venous return was achieved through the right femoral vein and the main pulmonary artery. Total circulatory arrest time was 30 minutes. Postoperative recovery was uneventful, and he left the hospital on the 10th postoperative day fully recovered except for left recurrent laryngeal nerve paresis. His blood pressure was easily controlled with atenelol 25 mg once daily. On discharge, his ankle-brachial index was 0.85 bilateral. Follow-up computed tomography angiogram confirmed intact repair and patent graft (C), and at 6-month follow-up, he is fully active and back to profession. The combination of significant coarctation of the aorta and a type B equivalent dissection is an extremely rare event. 1 It requires resection of the segment of aorta involved along with the coarctation segment and aortic continuity re-established with an interposed tubular polyester graft under aid of CPB. The procedure could be hazardous, particularly with regard to hemostatic control of the large intercostal arteries feeding into the aneurysm and injury to the pulmonary artery, the phrenic, and the recurrent laryngeal nerve. Postrepair paraplegia is a greater than usual hazard because of the need to sacrifice intercostal arteries. 2 Circulatory arrest allows for the accurate repair of this difficult pathologic process and avoids the risk of clamprelated injuries. 3 Endovascular repair in this setting of complex thoracic aortic pathology in this 40-year-old patient is limited or nonavailable, hence open surgery is life saving, durable, and is currently an exclusive therapeutic strategy.

Aortoesophageal Fistula and Coarctation of the Aorta in a 15-Year-Old Child

“…4 There are several reports of patients with undiagnosed or untreated coarctation of the aorta that developed postcoarctation aneurysms. 5 -10 Zhu et al 9 report that postcoarctation aortic aneurysms form in 17% of unrepaired coarctations. The proposed mechanism for aneurysm formation is postcoarctation turbulent blood flow causing endothelial trauma and subsequent seeding of microorganisms at the site of damaged endothelium.…”