Extra anatomical bypass for complex coarctation of aorta in an adult—a case report

Abstract

The surgical management of complex coarctation in an adult remains a challenge till date. Various surgical options are available in treating complex coarctation in adult including anatomical and extra anatomical corrections. Percutaneous intervention has very limited role, and an option is still uncertain. We are reporting a 28 year old male with complex coarctation of aorta who underwent an Extra Anatomocal Bypass using 22 mm Dacron graft from ascending aorta to descending aorta through midline sternotomy using posterior pericardial approach. He had uneventful postoperative period with acceptable gradients between both limbs. He remains asymptomatic on one year follow up with reduced need of antihypertensive medication.Twenty-eight year old male, a known hypertensive for 4 years on irregular medication presented with history of New York Heart Association (NYHA) Class II dyspnoea of 2 year duration. He also had giddiness on exertion, Claudication pain over the both lower limb (Claudication distance was 200 m) and numbness over the left upper limb of 2 months duration. On examination, he was well built with pulse rate of 76/min. Both lower limb pulses including both femoral pulses were absent. Left Brachial and radial pulses were feeble. Right upper limb and bilateral carotid artery pulses were well felt. His blood pressure on the right upper limb and left upper limb on supine posture was 160/100 and 110/90 respectively. There was no recordable lower limb blood pressure. A grade 2/6 ejection systolic murmur was heard over the aortic area. Bilateral carotid artery bruit was also heard. His biochemical and haematological investigation were within normal limits. 12 lead electrocardiogram showed left ventricular hypertrophy with strain pattern. Chest roentgenogram (Fig. 1) showed cardiomegaly with cardiothoracic ratio of 65% with mediastinal widening (dilated ascending aorta (28 mm) and left subclavian artery). 2 dimensional Transthoracic Echocardiogram showed complex coarctation of aorta involving the distal arch as well as proximal descending aorta with Peak gradient of 40 mmhg and mean gradient of 20 mmhg. Aortic valve was normal. Computed Aortogram showed complex coarctation of aorta with discrete narrowing in the distal arch between the left common carotid artery and Left subclavian artery with another narrowing between the left subclavian artery and proximal descending aorta with post stenotic dilatation of left subclavian artery and evidence of multiple chest wall collaterals (Fig. 2).He was planned for extra anatomical bypass in view of complexity of disease and technical difficulty as well as morbidity and mortality associated with anatomical approach. Through midline sternotomy, mild hypothermic cardiopulmonary bypass was established by cannulating the ascending aorta and two stage single venous cannula through the right atrium. Left ventricle was vented through right superior pulmonary venous cannula. With heart beating, Starfish suction apparatus (Medtronic, USA) was applied on the left ventricle apex and ...