Complications of Extra-Anatomic Aortic Bypass for Complex Coarctation and Aortic Arch Hypoplasia

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1 Complications of Extra-Anatomic Aortic Bypass for Complex Coarctation and Aortic Arch Hypoplasia Johann Brink, MD, Melissa G.Y. Lee, BMedSc, Igor E. Konstantinov, MD, PhD, Michael M.H. Cheung, MD, T.H. Goh, MD, Martin Bennett, BAppSc, Christian P. Brizard, MD, and Yves d Udekem, MD, PhD Departments of Cardiac Surgery, and Cardiology, The Royal Children s Hospital, Department of Pediatrics, University of Melbourne and the Murdoch Childrens Research Institute, Melbourne; and Department of Cardiology, Monash Medical Centre, Clayton, Victoria, Australia Background. We have adopted the extra-anatomic bypass graft as the procedure of choice for the treatment of coarctation and aortic arch hypoplasia in the adult-sized patient. However, we have experienced prolonged chest drainage and have decided to investigate this complication and the morbidity related to this procedure. Methods. Between 1996 and 2010, 15 extra-anatomic bypass grafts of the aorta were performed in 14 patients. Their hospital records and follow-up data were retrospectively reviewed and compared with those of 14 consecutive patients operated with other conventional techniques over the same time period. Results. There was no hospital mortality. After the extra-anatomic bypass procedure, patients had longer hospital stay because of prolonged pleural effusions. Four patients developed complications related to persistent effusions leading to reinterventions, which led to mediastinitis in 2 instances. At last follow-up, 2 of 14 patients with extra-anatomic bypass remained hypertensive, while 8 of the 14 patients who underwent other types of repair had arch obstruction, were hypertensive, or both. Conclusions. In the adult-sized patient extra-anatomic bypass of the aortic arch relieves arch obstruction more effectively than conventional techniques. However, this technique is fraught with complications related to prolonged effusion drainage that may lead to mediastinitis and reintervention. Its indication should be weighted carefully. (Ann Thorac Surg 2013;95:676 81) 2013 by The Society of Thoracic Surgeons Coarctation repair should be performed in early infancy because the patients are at higher risk of developing hypertension later in life if they are older at the time of repair [1 6]. At times, this procedure has to be carried out in adolescents and adults when they present with a late diagnosis or when they are diagnosed with residual obstruction related to either the operated site or to a segment of unoperated hypoplastic arch. It has been advocated that the most practical and effective technique of coarctation repair for these indications in adultsized patients is an extra-anatomic bypass graft interposed between the side of the ascending aorta and the descending aorta in the posterior mediastinum because it relieves any arch obstruction more effectively than conventional techniques [7 9]. The resection of the abnormal aortic segment and end-to-end anastomosis can only be performed with difficulty in adults because the tissues cannot be adequately mobilized. Graft patching of the restricted area through a thoracotomy is favored by some but requires extensive dissection, posing a risk of damage to the left recurrent laryngeal and phrenic nerves if cardiopulmonary bypass is required [10]. Graft patching of the arch through a sternotomy requires Accepted for publication Sept 4, Address correspondence to Dr d Udekem, Department of Cardiac Surgery, The Royal Children s Hospital, Flemington Rd, Parkville, Melbourne, Victoria 3052, Australia; yves.dudekem@rch.org.au. extensive dissection, circulatory arrest, or a strategy of regional perfusion, and poses risk to the left recurrent laryngeal nerve. We have adopted the extra-anatomic bypass graft through sternotomy approach in recent years. We have faced complications related to prolonged chest drainage and decided to investigate the morbidity related to this procedure. Patients and Methods The design of the study was approved by the Royal Children s Hospital Research Ethics Committee and the need for individual consent was waived because of the retrospective nature of the project. All patients who had undergone an extraanatomic bypass of the aortic arch through a sternotomy in the Royal Children s Hospital were identified in the hospital database. All their hospital records were reviewed and their follow-up was obtained from the hospital database and requested from their referring cardiologists. Between 1996 and 2010, 15 extra-anatomic bypass grafts of the aorta were performed in 14 patients. Patient characteristics are summarized in Table 1. Surgical Technique Procedures were performed through a median sternotomy with cardiopulmonary bypass and systemic cooling to 34 C. The heart was retracted to expose the posterior pericardium. The procedure was performed on the beat by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 Ann Thorac Surg BRINK ET AL 2013;95: EXTRA-ANATOMIC BYPASS PROCEDURE 677 Table 1. Patient Characteristics Characteristic Extra-Anatomic Conventional Gender (M:F) 11 (79%):3 (21%) 12 (86%):2 (14%) Age at current arch operation (years) Associated cardiac anomalies Bicuspid aortic valve 5 (36%) 5 (36%) VSD 3 (21%) 5 (36%) Supravalvular aortic stenosis 2 (14%) 1 (7%) Parachute mitral valve 2 (14%) 0 (0%) Truncus arteriosus 0 (0%) 2 (14%) Pulmonary stenosis 1 (7%) 1 (7%) Subaortic membrane 1 (7%) 0 (0%) Supra mitral valve ring 1 (7%) 0 (0%) Double AA vascular ring 1 (7%) 0 (0%) Ebstein anomaly 0 (0%) 1 (7%) Hypoplastic left heart syndrome 0 (0%) 1 (7%) Previous non-arch cardiac operation 4 (29%) 6 (43%) Previous arch intervention 9 (64%) 14 (100%) Balloon dilatation 3 (33%) 3 (21%) Sternotomy 3 (33%) 5 (36%) End-to-side anastomosis 1 0 Patch repair 1 2 Graft interposition 1 3 Thoracotomy 2 (23%) 5 (36%) End-to-end anastomosis 1 2 Subclavian flap aortoplasty 1 3 Others 1 (11%) 1 (7%) Indication for current arch surgery Native coarctation 2 (14%) 1 (7%) Native coarctation hypoplastic arch 3 (22%) 0 (0%) Recoarctation hypoplastic arch 9 (64%) 12 (86%) Aneurysm 0 (0%) 1 (7%) Mean resting pre-op BP (mm Hg) / /76 15 AA aortic arch; BP blood pressure; VSD ventricular septal defect. ing heart in 10 instances. The heart was arrested in 3 patients because of the need for concomitant procedures and in 2 patients following the surgeon s discretion. The distal descending thoracic aorta was exposed through a vertical incision in the posterior pericardium. A sideclamp was applied to the descending aorta and the distal end-to-side anastomosis was performed between the graft and a longitudinal incision of the aorta. In 3 patients the femoral artery pressure was continuously monitored at the time of clamping to ensure that distal perfusion was maintained during cross-clamping. The grafts used in the initial 14 procedures were Intergard woven collagen coated polyester (Intervascular; Datascope, La Ciotat Cedex, France) in 12 patients, and Gore-Tex (Vascular Graft; W.L. Gore & Associates Inc, Flagstaff, AZ) in 2 patients. The diameters of the vascular grafts used were 16 mm (1), 18 mm (1), 20 mm (10), and 22 mm (2). The side-clamp was removed and the graft was clamped. In 12 patients the graft was passed on the right side of the heart. The pericardial reflection between the right inferior pulmonary vein and the inferior vena cava was largely opened. The graft was then aligned along the diaphragmatic surface of the right ventricle, passed posterior to the inferior vena cava and brought on the lateral side of the right atrium to reach the ascending aorta. The graft was slightly beveled and the end-to-side proximal anastomosis to the ascending aorta was performed with side-bite clamping (Fig 1). In 2 patients the graft was passed on the left side of the heart, anterior to the left lung hilum and anastomosed to the left side of the ascending aorta. In the patient who required a second extra-anatomic bypass graft, Intergard was the material used but with a larger diameter of 22 mm instead of 18 mm; the graft was passed onto the right side of the heart. The chest was closed with a minimum of 2 chest drains. All patients had mediastinal drains; in addition, 4 patients had 1 pleural cavity drained and 1 patient both pleural cavities. Antiplatelet therapy with Aspirin (Aspro Clear, Bayer, Gaillard, France) was initiated on the first postoperative day.

3 678 BRINK ET AL Ann Thorac Surg EXTRA-ANATOMIC BYPASS PROCEDURE 2013;95: Student t test was used to analyze patients resting blood pressure before and after the extra-anatomic bypass operation and other techniques of arch repair, and a non-paired Student t test to compare early outcomes between the 2 arch procedure groups. A p value of less than 0.05 was considered evidence of statistical significance. Data were expressed as mean standard deviation or median (interquartile range). Fig 1. Extra-anatomic aortic bypass graft procedure. Comparative Analysis With Early Postoperative Outcomes After Conventional Techniques In order to compare outcomes after extra-anatomic aortic bypass with those after other techniques of arch repair, our database was searched for patients of similar age (above 12 years) undergoing an arch operation during the study period (1996 to 2010). A total of 14 patients were identified. Definitions Resting hypertension for children and adolescents was defined as a systolic or diastolic blood pressure greater than the 95th percentile for age and height and prehypertension between the 90th and 95th percentile or if blood pressure was greater than 120/80 mm Hg [11]. In adults, resting hypertension was defined as a systolic blood pressure greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg [12]. Reobstruction of the arch was defined as a peak gradient greater than 25 mm Hg across the repair site on echocardiography, or an upper limb to lower limb blood pressure gradient greater than 20 mm Hg. Statistical Analysis All data were exported to and analyzed using STATA version 10.1 (Stat Corp, College Station, TX). A paired Results Fifteen extra-anatomic bypass procedures were performed in 14 patients. All but 1 patient were hypertensive preoperatively. Four patients underwent the following concomitant procedures: aortic valve repair (1); aortic valve repair and ventricular septal defect closure (1); right ventricle to pulmonary artery conduit replacement (1); and redo repair of supravalvular aortic valve obstruction (1) (Table 2). Five patients underwent cardioplegic arrest. Mean cardiopulmonary bypass and cross-clamp time were and minutes, respectively. There was no hospital mortality. The median intensive care unit stay was 1 day (1 1) and all patients were discharged home after a median hospital stay of 9 days (7 13). The drains had to be kept in situ for more than a week in 8 patients (Table 3). Over a median of 6 days (5 9), the mean drainage output was 6 2 ml/kg per day. Triglyceride content was tested in the pleural effusion of 4 patients and was found to be below 0.5 mmol/l in all cases. Four patients required readmission after discharge. Two patients developed recurrent effusion and mediastinitis that required surgical intervention. The first of the patients with mediastinitis had all drains removed on day 4 and was discharged on the postoperative day 10. He subsequently developed Staphylococcus aureus sepsis and a false aneurysm. On postoperative day 62 the graft was removed and a homograft patch aortoplasty of the descending aorta was performed. The patient developed a recurrent false aneurysm 2 years later and required another extra-anatomic aortic bypass procedure as well as an aorta reconstruction with a homograft. Four years after the second extra-anatomic bypass, this same patient developed recurrent graft sepsis and a false aneurysm that required septic graft removal and right subclavianto-iliac arteries bypass graft. The second of these patients with mediastinitis developed a graft kink and required a graft interposition procedure 14 years after the initial extra-anatomic aortic bypass repair, which was performed at the age of 12 years. This patient had his drains removed on day 5 and developed postoperative Staphylococcus aureus mediastinitis requiring drainage. Another 2 patients required readmission, one 10 days and one 13 days after their initial hospital discharge for drainage of pleural and pericardial effusions. The mean follow-up was months. The mean age at follow-up was 18 4 years. One patient died in a motorbike accident 5 years after the extra-anatomic aortic bypass. At last follow-up 3 months prior to the

4 Ann Thorac Surg BRINK ET AL 2013;95: EXTRA-ANATOMIC BYPASS PROCEDURE 679 Table 2. Surgical Technique and Late Outcomes Variable Extra-Anatomic Conventional Surgical arch technique Sternotomy 14 (100%) 6 (43%) Extra-anatomic aortic bypass 14 0 Arch patch with homograft 0 2 Arch patch with Dacron graft 0 1 Extended end-to-end anastomosis 0 2 Gore-Tex graft interposition 0 1 Thoracotomy 0 (0%) 8 (57%) Gore-Tex graft interposition 0 5 End-to-end anastomosis 0 2 Arch patch with Dacron graft 0 1 Concomitant surgery 4 (29%) 3 (21%) AV repair AV repair VSD closure RV-PA conduit replacement Redo repair of supra-av obstruction VSD closure Revision of PA reconstruction Ross procedure RV-PA conduit Number of patients with follow-up 14 (100%) 13 (93%) Mean follow-up time (months) Mean age at follow-up (years) Arch reobstruction at follow-up Not applicable 6 (46%) Resting hypertension at last follow-up 2 (14%) 5 (38%) Mean resting BP at follow-up (mm Hg) / /65 15 AV aortic valve; BP blood pressure; PA pulmonary artery; RV right ventricle; VSD ventricular septal defect. accident, the patient was normotensive on both resting and 24-hour ambulatory blood pressure. The mean resting systolic blood pressure decreased from mm Hg to mm Hg (p 0.006) postoperatively. Two patients remained hypertensive at last follow-up (Table 2). Comparison With Conventional Techniques of Arch Repair All patients were hypertensive prior to surgery. Hospital stay was shorter for these 14 patients undergoing an intervention different to an extra-anatomic aortic bypass (mean length of stay 7 1vs12 11 days; p 0.07). Their drains were kept for shorter lengths of time (4 2vs7 3 days; p 0.003) and their drains output was less (2 1 vs 6 2 ml/kg/day; p 0.001) (Table 3). No patients were Table 3. Postoperative Pericardial Drainage Features and Clinical Impact readmitted for drainage of residual or reaccumulated effusions. Follow-up was available in 13 patients (93%) (Table 2). The mean follow-up was months and mean age at follow-up was 16 3 years of age. Six patients (46%) had reobstruction on echocardiography (2 were operated using a Gore-Tex graft interposition by thoracotomy, 2 end-to-end anastomosis by thoracotomy, 1 patch enlargement of the arch with homograft patch through sternotomy, and 1 extended end-to-end anastomosis through sternotomy). The 2 patients who had an end-toend anastomosis by thoracotomy remained hypertensive. An additional 3 patients were found to be hypertensive at last follow-up. All of them had undergone a Gore-Tex graft interposition (2 through thoracotomy, 1 through sternotomy). The mean resting systolic blood pressure decreased from mm Hg to mm Hg (p 0.008) postoperatively. Variable Total drainage (ml) Total drainage (ml/kg/day) Drains in situ (days) Hospital stay (days) Extra-Anatomic Bypass Procedures (n 15) Conventional Procedures p Value 2,547 1, Comment Historical data from the early nineties demonstrated that hypertension may be lethal when it develops in young adults late after coarctation repair and in adults newly diagnosed with coarctation of the aorta. In the largest and longest study to date from the Mayo clinic, mortality as high as 28% was recorded in the three decades following arch repair [1]. This mortality was attributed to complications related to residual hypertension such as precocious coronary artery disease and from rupture of ab-

5 680 BRINK ET AL Ann Thorac Surg EXTRA-ANATOMIC BYPASS PROCEDURE 2013;95: dominal aortic and cerebral aneurysms. These data, long disregarded as historical, are regaining interest with increasing evidence that the incidence of late hypertension is higher than expected in these patients [13, 14]. All mechanisms leading to late hypertension after coarctation repair have not yet been fully elucidated, but it has been clearly demonstrated that residual obstruction [2, 15] and later age at repair are obvious contributing factors [1 6]. A large proportion of babies born with coarctation also have hypoplasia of the transverse aortic arch. It has become clear that the impact of this hypoplasia has been overlooked in previous decades and an increasing population of these young adults are now presenting with hypertension, often refractory to medical treatment [2]. It is yet unclear whether the relief of any arch obstruction will be sufficient to protect these patients from suffering from late hypertension [2, 16]. Nonetheless, the urgency of treating rapidly and effectively any arch obstruction has formed the rationale for a preferential choice of procedure that will give the best chance of immediate relief. While recurrent stenosis at the site of the previous anastomosis is best dealt with an interventional catheterization procedure, a number of these patients will present with complex hypoplastic lesions of the arch not accessible to balloon dilatation and stenting. Accordingly, surgery remains the favored option. Beyond infancy, end-to-end anastomosis, conventionally used in babies born with coarctation repair, can only be achieved with considerable difficulty because the aortic tissues have lost their elasticity. The long-term results of bypass grafting and patching of the arch have not been yet reported in this specific population of patients reaching an adult size. Extra-anatomic bypass of the arch through a sternotomy has been identified as the best approach in these patients because of its simplicity and its capacity to adequately relieve any obstruction without compromising the left phrenic and the left recurrent laryngeal nerve [7, 9]. Potential difficulties during reoperation in this population of patients with a high incidence of bicuspid aortic valves have not deterred the teams advocating this approach. Following the experience of stenting of adult coarctation, it has been advocated that the loss of elasticity of a segment of aortic arch may lead to hypertension, and it is yet unclear whether the interposition of a long segment of a rigid tubular graft will spare patients from late hypertension [17]. At this stage of our experience, we can conclude that extra-anatomic bypass of the arch has been more effective in relieving the arch obstruction than other techniques we have used over the same time period. Eight of the 14 patients operated with conventional techniques developed residual obstruction, hypertension, or both. Only 2 of the 14 patients undergoing an extra-anatomic bypass remained hypertensive. However, we are concerned by the morbidity associated with this procedure. In our institution, these patients had prolonged hospital stays because of ongoing chest drain losses. They also required repeated hospital admissions due to fluid recollection with subsequent surgical intervention. There is no doubt in our minds that overlooking these chest drain losses were responsible for the dramatic morbidity observed in the 2 young patients suffering early graft infection. The use of extra-anatomic bypass in our center was associated with an increased morbidity compared with the various more conventional techniques of arch repair used over the same time period, and we believe that the encountered prolonged effusions may have been related to the intrapericardial implantation of a long segment of Dacron graft. Vascular surgeons have long been aware of prolonged effusion drainage and perigraft collections after aortic bypass grafting of the abdominal aorta. Graft hemorrhage may occur due to poor anastomotic quality, device failure or rupture, and trans-graft hemorrhage. Because of the serosanguinous nature of the effusions and the time frame of their appearance, we believe that the prolonged effusions suffered by our patients were related to transudation of plasma through the grafts. Graft impermeability depends on the porosity and quality of graft healing. It has already been postulated that poor tissue growth in the mediastinum and the initial expansion and early dilatation observed in woven vascular Dacron [18] grafts may contribute to transgraft hemorrhage [19]. Preliminary reports with a third-generation Dacron graft seem to give promising results [20]. It is comprised of a triple layer composed of standard woven Dacron fused to a polytetrafluoroethylene outer layer by a self-sealing elastomeric membrane, making this graft highly impermeable but also slightly stiffer. This graft might be a possible alternative to prevent excessive early transgraft hemorrhage. We believe that surgeons who adopt this technique of extra-anatomic bypass should be aware of the potential for prolonged postoperative drainage of mediastinal and pleural effusions. We hope that prolonged and adequate drainage of these effusions will prevent the development of the complications that we observed in our patients. Our limited experience with the conventional techniques does not allow us to ascertain the best alternatives for this technique and their relative indications. Because of our high rate of residual obstruction, we tend to believe that any hypoplasia of the arch should be operated through a sternotomy. We believe that graft patching of the arch should be considered in these instances as an alternative to extra-anatomic bypass. The decision of the technique used should take into consideration the urgency of relieving the hypertension and the difficulty of an intervention on the native arch. This decision may need to be customized to the individual patient. In conclusion, in the adult-sized patient extra-anatomic bypass of the aortic arch relieves arch obstruction more effectively than conventional techniques. However, this technique is fraught with complications related to prolonged effusion drainage that may lead to mediastinitis and reintervention. Its indication should be weighted carefully.

6 Ann Thorac Surg BRINK ET AL 2013;95: EXTRA-ANATOMIC BYPASS PROCEDURE 681 Dr Yves d Udekem is a Career Development Fellow of The National Heart Foundation of Australia (CR 10M 5339). This research project was supported by the Victorian Government s Operational Infrastructure Support Program. References 1. Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation 1989; 80: Hager A, Kanz S, Kaemmerer H, Schreiber C, Hess J. Coarctation Long-term Assessment (COALA): significance of arterial hypertension in a cohort of 404 patients up to 27 years after surgical repair of isolated coarctation of the aorta, even in the absence of restenosis and prosthetic material. J Thorac Cardiovasc Surg 2007;134: Seirafi PA, Warner KG, Geggel RL, Payne DD, Cleveland RJ. Repair of coarctation of the aorta during infancy minimizes the risk of late hypertension. Ann Thorac Surg 1998;66: Presbitero P, Demarie D, Villani M, et al. Long term results (15-30 years) of surgical repair of aortic coarctation. Br Heart J 1987;57: Clarkson PM, Nicholson MR, Barratt-Boyes BG, Neutze JM, Whitlock RM. Results after repair of coarctation of the aorta beyond infancy: a 10 to 28 year follow-up with particular reference to late systemic hypertension. Am J Cardiol 1983; 51: Maron BJ, Humphries JO, Rowe RD, Mellits ED. Prognosis of surgically corrected coarctation of the aorta. A 20-year postoperative appraisal. Circulation 1973;47: McKellar SH, Schaff HV, Dearani JA, et al. Intermediateterm results of ascending-descending posterior pericardial bypass of complex aortic coarctation. J Thorac Cardiovasc Surg 2007;133: Levy Praschker BG, Mordant P, Barreda E, Gandjbakhch I, Pavie A. Long-term results of ascending aorta-abdominal aorta extra-anatomic bypass for recoarctation in adults with 27-year follow-up. Eur J Cardiothorac Surg 2008;34: 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: Sakopoulos AG, Hahn TL, Turrentine M, Brown JW. Recurrent aortic coarctation: is surgical repair still the gold standard? J Thorac Cardiovasc Surg 1998;116: National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114(2 Suppl 4th Report): Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289: O Sullivan JJ, Derrick G, Darnell R. Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement. Heart 2002;88: de Divitiis M, Pilla C, Kattenhorn M, et al. Ambulatory blood pressure, left ventricular mass, and conduit artery function late after successful repair of coarctation of the aorta. J Am Coll Cardiol 2003;41: Guenthard J, Zumsteg U, Wyler F. Arm-leg pressure gradients on late follow-up after coarctation repair. Possible causes and implications. Eur Heart J 1996;17: Hauser M, Kuehn A, Wilson N. Abnormal responses for blood pressure in children and adults with surgically corrected aortic coarctation. Cardiol Young 2000;10: Eicken A, Pensl U, Sebening W, et al. The fate of systemic blood pressure in patients after effectively stented coarctation. Eur Heart J 2006;27: Etz CD, Homann T, Silovitz D, et al. Vascular graft replacement of the ascending and descending aorta: do Dacron grafts grow? Ann Thorac Surg 2007;84: Shiiya N, Kunihara T, Matsuzaki K, Sugiki T. Spontaneous perigraft hematoma suggesting transgraft hemorrhage seven years after thoracic aortic replacement with a Dacron graft. Eur J Cardiothorac Surg 2006;30: De Paulis R, Scaffa R, Maselli D, Salica A, Bellisario A, Weltert L. A third generation of ascending aorta Dacron graft: preliminary experience. Ann Thorac Surg 2008;85:

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