Mid- to long-term outcomes of median sternotomy ascending-descending thoracic aortic bypass grafting for complex aortic coarctation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

JIN Yongqiang , FAN Lixin , ZHANG Enrui , ZHANG Xiaoya , XUE Hui , XU Zhonghua ,  WU Qingyu

Heart Center, First Hospital of Tsinghua University, Beijing, 100016, P. R. China;

Corresponding author：

WU Qingyu, Email: wuqingyu@mail.tsinghua.edu.cn

Keywords：

Ascending-descending thoracic aortic bypass grafting; coarctation of aorta; median sternotomy; mid- to long-term outcomes

DOI：

10.7507/1007-4848.202407044

Video：

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Objective To summarize the experience with median sternotomy ascending-descending thoracic aortic bypass grafting via median sternotomy for the treatment of complex coarctation of aorta (COA), and to present the intermediate to long-term follow-up outcomes. Methods A retrospective analysis was performed on patients with complex COA who underwent ascending-descending thoracic aortic bypass grafting through a median sternotomy in the First Hospital of Tsinghua University from August 2004 to May 2017. Results A total of 7 children were enrolled, including 4 males and 3 females, with an average age of (13.3±4.6) years and an average weight of (40.2±12.2) kg. Six (85.7%) patients had hypertension in the upper limbs. Among them four patients had coarctation associated with intracardiac anomalies, two with recurrent coarctation post-surgery, and one with both recurrent coarctation and intracardiac anomalies. All surgeries were performed under cardiopulmonary bypass, with no operative mortality or severe complications. The systolic pressure gradient between the upper and lower extremities decreased significantly from preoperative (51.4±13.5) mm Hg to postoperative (2.9±2.7) mm Hg (P<0.01). During a follow-up period of (14.9±5.9) years (ranging from 7 to 19 years), there were no late deaths or graft-related complications. Except for one patient who continued to have mild hypertension, the blood pressure of all other patients returned to normal. Conclusion The ascending-descending thoracic aortic bypass grafting via median sternotomy for complex COA is a safe and reliable procedure that effectively reduces upper limb blood pressure and the pressure difference between the upper and lower extremities. It has a low rate of complications and satisfactory intermediate to long-term outcomes.

1.	Singh S, Hakim FA, Sharma A, et al. Hypoplasia, pseudocoarctation and coarctation of the aorta—A systematic review. Heart Lung Circ, 2015, 24(2): 110-118.
2.	Kreuzer M, Sames-Dolzer E, Klapper M, et al. The anatomic repair of recurrent aortic arch obstruction in children and adolescents. JTCVS Open, 2024, 19: 215-222.
3.	Edie RN, Janani J, Attai LA, et al. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg, 1975, 20(5): 558-566.
4.	Aboulhosn J, Child JS. Left ventricular outflow obstruction: Subaortic stenosis, bicuspid aortic valve, supravalvar aortic stenosis, and coarctation of the aorta. Circulation, 2006, 114(22): 2412-2422.
5.	Jenkins NP, Ward C. Coarctation of the aorta: Natural history and outcome after surgical treatment. QJM, 1999, 92(7): 365-371.
6.	Campbell M. Natural history of coarctation of the aorta. Br Heart J, 1970, 32(5): 633-640.
7.	Foster ED. Reoperation for aortic coarctation. Ann Thorac Surg, 1984, 38(1): 81-89.
8.	Sweeney MS, Walker WE, Duncan JM, et al. Reoperation for aortic coarctation: Techniques, results, and indications for various approaches. Ann Thorac Surg, 1985, 40(1): 46-49.
9.	Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg, 2000, 70(1): 31-37.
10.	Wu Q, Chen X, Li H, et al. Ascending-to-descending aortic bypass via posterior pericardium for complex coarctation of aorta. J Card Surg, 2009, 24(2): 167-169.
11.	Wukasch DC, Cooley DA, Sandiford FM, et al. Ascending aorta-abdominal aorta bypass: Indications, technique, and report of 12 patients. Ann Thorac Surg, 1977, 23(5): 442-448.
12.	胡晓鹏, 于存涛, 钱向阳, 等. 正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形. 中国胸心血管外科临床杂志, 2009, 16(4): 270-273.Hu XP, Yu CT, Qian XY, et al. Extra-anatomic aortic bypass grafting through median sternotomy for one-stage treatment of aortic coarctation and associated cardiac diseases. Chin J Clin Thorac Cardiovasc Surg, 2009, 16(4): 270-273.
13.	Jasper A, Harshe G, Keshava SN, et al. Evaluation of normal abdominal aortic diameters in the Indian population using computed tomography. J Postgrad Med, 2014, 60(1): 57-60.
14.	Kumar MV, Choudhary SK, Talwar S, et al. Extraanatomic bypass to supraceliac abdominal aorta for complex thoracic aortic obstruction. Ann Thorac Surg, 2016, 101(4): 1552-1557.
15.	Cho S, Lee CH, Kim ER, et al. Outcomes of aortic coarctation surgical repair in adolescents and adults. Interact Cardiovasc Thorac Surg, 2020, 30(6): 925-931.
16.	Canniffe C, Ou P, Walsh K, et al. Hypertension after repair of aortic coarctation—A systematic review. Int J Cardiol, 2013, 167(6): 2456-2461.
17.	Brown ML, Burkhart HM, Connolly HM, et al. Coarctation of the aorta: Lifelong surveillance is mandatory following surgical repair. J Am Coll Cardiol, 2013, 62(11): 1020-1025.
18.	Said SM, Burkhart HM, Dearani JA, et al. Ascending-to-descending aortic bypass: A simple solution to a complex problem. Ann Thorac Surg, 2014, 97(6): 2041-2047.
19.	Grinda JM, Macé L, Dervanian P, et al. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg, 1995, 60(5): 1299-1302.
20.	Berdat PA, Göber V, Carrel T. Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults. Interact Cardiovasc Thorac Surg, 2003, 2(2): 133-137.
21.	Al-Husayni F, Samman A, Althobaiti M, et al. Late complications after previous surgical repair for coarctation with extra-anatomic bypass graft: Report on two cases. Cureus, 2021, 13(1): e12722.

1. Singh S, Hakim FA, Sharma A, et al. Hypoplasia, pseudocoarctation and coarctation of the aorta—A systematic review. Heart Lung Circ, 2015, 24(2): 110-118.
2. Kreuzer M, Sames-Dolzer E, Klapper M, et al. The anatomic repair of recurrent aortic arch obstruction in children and adolescents. JTCVS Open, 2024, 19: 215-222.
3. Edie RN, Janani J, Attai LA, et al. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg, 1975, 20(5): 558-566.
4. Aboulhosn J, Child JS. Left ventricular outflow obstruction: Subaortic stenosis, bicuspid aortic valve, supravalvar aortic stenosis, and coarctation of the aorta. Circulation, 2006, 114(22): 2412-2422.
5. Jenkins NP, Ward C. Coarctation of the aorta: Natural history and outcome after surgical treatment. QJM, 1999, 92(7): 365-371.
6. Campbell M. Natural history of coarctation of the aorta. Br Heart J, 1970, 32(5): 633-640.
7. Foster ED. Reoperation for aortic coarctation. Ann Thorac Surg, 1984, 38(1): 81-89.
8. Sweeney MS, Walker WE, Duncan JM, et al. Reoperation for aortic coarctation: Techniques, results, and indications for various approaches. Ann Thorac Surg, 1985, 40(1): 46-49.
9. Izhar U, Schaff HV, Mullany CJ, et al. Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy. Ann Thorac Surg, 2000, 70(1): 31-37.
10. Wu Q, Chen X, Li H, et al. Ascending-to-descending aortic bypass via posterior pericardium for complex coarctation of aorta. J Card Surg, 2009, 24(2): 167-169.
11. Wukasch DC, Cooley DA, Sandiford FM, et al. Ascending aorta-abdominal aorta bypass: Indications, technique, and report of 12 patients. Ann Thorac Surg, 1977, 23(5): 442-448.
12. 胡晓鹏, 于存涛, 钱向阳, 等. 正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形. 中国胸心血管外科临床杂志, 2009, 16(4): 270-273.Hu XP, Yu CT, Qian XY, et al. Extra-anatomic aortic bypass grafting through median sternotomy for one-stage treatment of aortic coarctation and associated cardiac diseases. Chin J Clin Thorac Cardiovasc Surg, 2009, 16(4): 270-273.
13. Jasper A, Harshe G, Keshava SN, et al. Evaluation of normal abdominal aortic diameters in the Indian population using computed tomography. J Postgrad Med, 2014, 60(1): 57-60.
14. Kumar MV, Choudhary SK, Talwar S, et al. Extraanatomic bypass to supraceliac abdominal aorta for complex thoracic aortic obstruction. Ann Thorac Surg, 2016, 101(4): 1552-1557.
15. Cho S, Lee CH, Kim ER, et al. Outcomes of aortic coarctation surgical repair in adolescents and adults. Interact Cardiovasc Thorac Surg, 2020, 30(6): 925-931.
16. Canniffe C, Ou P, Walsh K, et al. Hypertension after repair of aortic coarctation—A systematic review. Int J Cardiol, 2013, 167(6): 2456-2461.
17. Brown ML, Burkhart HM, Connolly HM, et al. Coarctation of the aorta: Lifelong surveillance is mandatory following surgical repair. J Am Coll Cardiol, 2013, 62(11): 1020-1025.
18. Said SM, Burkhart HM, Dearani JA, et al. Ascending-to-descending aortic bypass: A simple solution to a complex problem. Ann Thorac Surg, 2014, 97(6): 2041-2047.
19. Grinda JM, Macé L, Dervanian P, et al. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg, 1995, 60(5): 1299-1302.
20. Berdat PA, Göber V, Carrel T. Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults. Interact Cardiovasc Thorac Surg, 2003, 2(2): 133-137.
21. Al-Husayni F, Samman A, Althobaiti M, et al. Late complications after previous surgical repair for coarctation with extra-anatomic bypass graft: Report on two cases. Cureus, 2021, 13(1): e12722.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

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