Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch

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1 Interactive CardioVascular and Thoracic Surgery 25 (2017) doi: /icvts/ivx115 Advance Access publication 11 May 2017 ORIGINAL ARTICLE Cite this article as: Delmo Walter EM, Javier MF, Hetzer R. Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch. Interact CardioVasc Thorac Surg 2017;25: Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch Eva Maria Delmo Walter*, Mariano Francisco del Maria Javier and Roland Hetzer Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany * Corresponding author. Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Unter den Linden 21, Berlin, Germany. Tel: ; eva.delmowalter@gmail.com (E.M. Delmo Walter). Received 10 October 2016; received in revised form 9 February 2017; accepted 15 February 2017 Abstract OBJECTIVES: Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch. METHODS: Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9 23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmhg at rest and 180 ± 40 mmhg during exercise, with a mean pressure gradient of 80 ± 11.6 (range ) mmhg. RESULTS: Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10 26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmhg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon. CONCLUSIONS: Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results. Keywords: Coarctation of aorta Recurrent aortic Coarctation Hypoplastic arch Extra-anatomical bypass Congenital heart disease INTRODUCTION With all of the surgical and catheter-related interventions presently available for native coarctation of the aorta (CoA) and hypoplastic arch, repeat operations may still be required due to restenosis or aneurysm formation. CoA remains a challenging entity in congenital cardiac surgery. Percutaneous balloon dilatation with or without stenting is often considered a therapeutic option for simple recoarctation [1 4]. However, CoA may be complex, presenting with long-segment coarctation and diffuse hypoplasia of the aortic arch, which may be complicated by anastomotic aneurysms from a previous repair and thus may not be suitable for catheter interventions. In these cases, surgical management appears to be formidable technically. Anatomical repair may require extensive dissection, cardiopulmonary bypass (CPB) and Presented at the 30th Annual Meeting of the European Association of Cardiothoracic Surgery Barcelona, Spain, 1 5 October deep hypothermic circulatory arrest, with their inherent risk of cerebrovascular complications [5, 6]. No one surgical procedure is universally accepted nor is there agreement whether left thoracotomy, median sternotomy or a combination of the 2 is the best approach. Heinemann et al. [7] recommended extra-anatomical thoracic aortic bypass for complex, recurrent aortic coarctation, aortic occlusive disease and complex aneurysm, which they performed in 17 patients. Robicsek [7], in his comment to Heinemann [7], stated that the authors have offered too extensive a menu to fit all the different pathological conditions. He added that a simple ascending aorta-to-infrarenal aortic bypass would have worked, which is the approach he would recommend. This statement prompted us to apply a simple technique of extra-anatomical bypass. The refinements in extracorporeal circulation and the perfection of synthetic vascular prostheses enabled us to perform extensive aortic operations using this technique. VC The Author Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

2 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery 401 We report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent CoA and hypoplastic aortic arch. PATIENTS AND METHODS The institutional review board approved this retrospective study and waived the need for patient consent. Patients Between 1989 and 2012, 53 patients (mean age 14.4 ± 5.8, median 12.7, range 9 23 years) with complex CoA (n = 33; longsegment hypoplastic aortic arch in 15) and recurrent coarctation (n = 20; anastomotic pseudoaneurysm in 10) were included in this series. Median body weight was 63.4 kg (range kg), mean height 164 cm (range cm), mean body mass index 23.5 (range 14 29) and mean body surface area 1.7 m 2 (range m 2 ). Complex CoA was defined in this setting as CoA with >5 cm stenosis, with associated diffuse hypoplasia (a proximal or distal transverse arch diameter of less than 50% of the diameter of the ascending aorta) of the aortic arch, or as coarctation associated with other cardiac lesions or complicated by a pseudoaneurysm. Hypoplastic aortic arch was defined as an arch whose diameter was less than 50% of the diameter of the ascending aorta. Longsegment aortic arch hypoplasia is defined as hypoplasia of >5 cm. Recurrent coarctation was defined as a previously repaired arch coarctation that returned. An anastomotic pseudoaneurysm is defined as an aneurysm arising from the anastomosis of a previously repaired CoA. There were 40 reoperations in 35 patients. Seven patients had undergone previous operations at least once, mostly resection and end-to-end anastomosis, subclavian flap or patch aortoplasty, or interposition of a polyester tube graft. Nine patients had a history of angioplasty and stenting. Reintervention in these patients became necessary due to a gradient of more than 30 mmhg, upper limb hypertension, claudication, or renal insufficiency. Patients baseline characteristics are summarized in Table 1. All patients presented with hypertension at rest (mean 130 ± 30, range mmhg) despite antihypertensive medication with a combination therapy of up to 4 agents and with excessively high blood pressure of 200 mmhg systolic during exercise in 6 patients. Extra-anatomical bypass procedures were implemented in conjunction with the referring paediatric cardiologists, who extensively used catheter-interventional procedures whenever possible. Operative selection strategy Use of extracorporeal circulation. The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplastic segment and a history of previous repair. Circulatory support during reoperations was used in patients with postcoarctation anastomotic aneurysms, inadequate collaterals demonstrated by a drop in pressure to <50 mmhg in the aorta distal to the test clamp or a significant increase in pressure proximal to the test clamp. In this group, Table 1: Characteristics of 60 patients who underwent extra-anatomical bypass for complex, recurrent coarctation and hypoplasia of the aortic arch from 1986 to 2012 Characteristics n =53 Mean (median, range) age, years 13.2 ± 4.3 (11.6, 9 23) Male/female 41/12 Complex coarctation 33 Long-segment hypoplastic arch 15 (5 previous interventions) Recurrent coarctation 20 (35 previous interventions) Anastomotic pseudoaneurysm 10 Concomitant cardiac disease Aortic valve stenosis 2 Aortic arch aneurysm 3 Bicuspid valve 4 Ventricular septal defect 3 Patent ductus arteriosus 7 Preoperative mean systolic blood pressure, mmhg At rest 130 ± 30 (90 150) During exercise 180 ± 40 ( ) Preoperative mean (range) 80 ± 11.6 (40 120) pressure gradient, mmhg Previous balloon dilatation 12 Previous stent implantation 9 Previous operation Repair of native coarctation 20 Interrupted aortic arch 3 Closure of ventricular septal defect 5 Coronary artery fistula 1 Patent ductus arteriosus 6 circulatory support was established between the left atrium and the descending aorta (femoral artery) left heart bypass. Alternatively, femoro-femoral bypass was used. Surgical approach. In patients who underwent repeat surgery, the surgical approach was dictated by the anatomy of the aortic arch. Patients having a normal arch or a moderately hypoplastic distal arch were operated on through a left lateral thoracotomy, much the same as that for the initial coarctation repair. Patients with residual or persistent hypoplastic arch, proximal or transverse, associated or not with recurrent coarctation were approached through a combined sternotomy and midline laparotomy. Surgical technique Subclavian artery descending aorta bypass. For recurrent coarctation, the graft was inserted between the subclavian artery and the proximal descending aorta (Fig. 1A), thereby avoiding extensive dissection in the previously scarred operative field. The prerequisite for sufficient relief of the pressure gradient is a large left subclavian artery, the diameter of which should be close to that of the distal descending thoracic aorta. Ascending aorta to descending aorta bypass graft. Usually via an extensive left lateral thoracotomy and exposure of both the ascending and descending aorta, the operation was performed with the patient on femoro-femoral CPB, with a beating heart. A partially occluding vascular clamp was used for the distal anastomosis of the graft to the descending thoracic aorta. After the distal anastomosis was completed, the graft was directed into CONGENITAL

3 402 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery cases, to achieve sufficient graft length, graft segments had to be joined together. Ascending to infrarenal aorta bypass. A combined median sternotomy and median laparotomy was applied. After opening both the pericardial and the peritoneal cavities, the longitudinal midline of the central tendon of the diaphragm was split and the left liver lobe was mobilized and shifted to the right. The omentum was opened above the stomach and a canal was formed via the bursa omentalis and the radix mesenterii without injuring any vessels. Below the radix, the infrarenal aorta was exposed and a side-biting clamp was applied after moderate heparinisation ( IU). The selected graft was cut obliquely and anastomosed to a longitudinal aortotomy with Prolene 4-0 sutures. The graft was then brought through the preformed canal to the incision in the diaphragm and placed in a loose curve along the right atrium to the right convex curve of the ascending aorta where it was anastomosed in an oblique end-to-side fashion after partial clamping of the aorta. Ascending aorta subclavian artery bypass. An ascending aorta subclavian artery bypass (Fig. 1C) was performed for persistent long-segment aortic arch hypoplasia with anastomotic aneurysm. Follow-up Figure 1: (A) Left sublavian artery to descending aorta bypass. (B) Ascending aorta to descending aorta bypass. (C) Ascending aorta to left subclavian artery bypass; red arrows indicates site of stenosis or hypoplasia. the left lateral pericardial sac and routed anteriorly to the pulmonary artery. Next, the graft was cut obliquely and anastomosed anteriorly to the ascending aorta using a side-biting clamp (Fig. 1B). Cardiac arrest and cardioplegia were necessary in 9 patients to close the ventricular septal defect in 3 and repair the aortic valve in 6. In the case of reoperations and when more extensive dissection of the arch and proximal descending thoracic aorta was necessary, a left lateral thoracotomy combined with an upper partial median sternotomy was used. This approach provided excellent access to the aortic arch. The ascending descending graft then followed a longer anterior and transverse route. In some All patients were followed up either at our outpatient department or by their respective cardiologists. Information on survival, cardiac and non-cardiac events and other complications (surgical/ non-surgical) were obtained from their ambulatory consultations and medical reports of the referring physicians. Follow-up is complete and was performed at 3, 6 and 12 months postoperatively, and then individually at least once a year, using 2D echocardiography, magnetic resonance imaging or computed tomographic scanning. Eighty-three percent of patients underwent postoperative magnetic resonance imaging (1.5-T SIGNA CV/i, GE Medical Systems, Waukesha, WI, USA) for evaluation of the aorta and graft with high-performance gradients and high-resolution cardiovascular images. Low dose antiplate aggregation therapy (aspirin, 100 mg/daily) was started on the second postoperative day and continued for at least 1 year. Statistical analysis Medical records were reviewed to obtain demographic characteristics, associated medical conditions, details of operations and results of the diagnostic examinations. All data were analysed with the SPSS statistical program for Windows, version 22.0 (SPSS Inc., Chicago IL, USA) software program. Data are expressed as absolute and percentage frequency values and continuous data as mean ± standard deviation, median and range, as appropriate. Descriptive statistics for categorical variables are reported as frequency and percentage, and continuous variables are reported as mean ± standard deviation or as median with the range, as appropriate. Cumulative survival was analysed according to Kaplan Meier estimates.

4 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery 403 RESULTS All patients underwent correction using extra-anatomical bypass, either with (n = 18; femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n = 30) and a combined median sternotomy and abdominal laparotomy (n = 5) approach. In 19 patients, concomitant aortic valve repair (n = 6), closure of a ventricular septal defect (n = 3), closure of a patent foramen ovale (n = 3) or closure of patent ductus arteriosus (n = 7) was carried out (Table 2). Intraoperatively, simultaneous direct pressure measurements of the vessels involved were performed before and after the grafts were placed. The mean values are shown in Table 3. In18 patients in whom extracorporeal circulation was used, the mean aortic cross-clamp time was 28 ± 32 (median 47, range 20 93) Table 2: strategy Operative characteristics, surgical approach and n =53 With extracorporeal circulation 18 Femoro-femoral bypass 13 Left heart bypass 5 (left atrium-descending aorta) Cardiopulmonary bypass time, 243 ± 125 (86, ) mean ± SD (median, range) min Ischaemic time, mean ± SD min 28 ± 32 (47, 20 93) Without extracorporeal circulation 35 Operative time, min ± (95, ) Surgical approach Via left lateral thoracotomy 48 Via combined median sternotomy 5 and midline laparotomy Bypass graft size, median (range) mm 18 (10 26) Extra-anatomical bypass LSCA to DA 38 AA to LSCA 3 AA to DA (including infrarenal aorta) 12 Concomitant procedures Closure of VSD 3 Closure of PFO 3 Closure of PDA 7 Aortic valve repair 6 SD: standard deviation; LSCA: left subclavian artery; DA: descending aorta; AA: ascending aorta; VSD: ventricular septal defect; PFO: patent foramen ovale; PDA: patent ductus arteriosus. Table 3: Simultaneous intraoperative direct pressure measurements during extra-anatomical bypass procedure Vessels involved Mean values (mmhg) Left subclavian artery ± 6.0 Descending aorta ± 4.0 Ascending aorta ± 4.0 Descending aorta ± 2.0 Ascending aorta ± 4.0 Left subclavian artery ± 2.0 min and the mean CPB time was 243 ± 125 (median 86, range ) min (Table 2). Graft size (median 18, range mm) was chosen according to the diameter of the vessels at the site of the anastomosis or depending on the diameter of the descending aorta. No bronchial compression was observed in patients with extraanatomical bypass from the ascending to the descending aorta. The mean stay in the intensive care unit was less than 1 day; the mean hospital stay was 8.2 ± 3.8 days (range 4 28 days). Postoperatively, the mean reduction in systolic blood pressure was 60 ± 25 mmhg without any pressure gradient (P < 0.001). Antihypertensive treatment, preferentially with beta-blockers, was continued for 2 months postoperatively and then reduced according to the patient s blood pressure at rest and during exercise. Early postoperative morbidity Postoperative haemorrhage occurred in 5 patients but only 1 patient needed a reoperation. Furthermore, chylothorax occurred in 1 and was successfully managed conservatively. One patient had pneumothorax that was relieved by placement of chest tube drains. Atrial fibrillation occurred in 2 that was relieved by beta blockers. One patient had a ventricular arrhythmia that was controlled with amiodarone. Late postoperative morbidity Sinus bradycardia occurred in a 23-year-old patient during early clinical follow-up for which a pacemaker was indicated. Early deaths There were no early deaths. Late mortality included 6 patients (11%) and was not related to the bypass graft; 5 patients died of unknown causes (based on attending physicians reports) 2, 6, 8 and 18 years postoperatively. Another patient died of rhythmic disturbances 18 years after the surgery. Follow-up The mean duration of follow-up was ± 1.5 years (range years). Freedom from reoperation No patient needed reintervention. There were no reoperations, graft complications or pseudoaneurysms on the anastomotic sites. Freedom from reoperation was 100% at the time of this report. However, we closely monitor and anticipate reoperations in 12 patients who were reoperated on when they were less than 18-years-old for change of graft length to accommodate growth. During the follow-up period (range years), there has been no need for other surgical or interventional procedures. No patients had recurrence of symptoms. All reported leading a normal existence with good quality of life. Echocardiography showed that all extra-anatomical bypass grafts were patent in all patients. In 83% of patients who underwent magnetic resonance imaging, the patency of the extra-anatomical bypass grafts was CONGENITAL

5 404 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery likewise confirmed (Figs 2A and B, 3A and B and 4A and B). There were no complications observed either with the extraanatomical bypass grafts, the subclavian arteries or the ascending and descending aorta. Beyond the anastomotic sites in the descending aorta, the mean pressure gradient was 3.1 ± 1.8 mmhg (range mmhg) with normal flow velocity of approximately 1 min/s. Themeanreductioninsystolicbloodpressurewas60±25mmHg without any residual gradients (P <0.001). The systemic arterial blood pressure of 46 patients (77.9%) was <120 mmhg/<90 mmhg (systolic/diastolic). Thirteen (22.0%) patients have mild/moderate hypertension: 2 patients are taking a diuretic, 3 are taking angiotensin-converting enzyme inhibitors whereas 8 patients are taking beta blockers. No patient has had paraplegia, signs of neurological complications or abdominal malperfusion. No patients presented with claudication nor did any patient experience orthostatic problems due to the steal phenomenon. We did not observe any pathological findings on any of the anastomoses, nor did any patient have a pseudoaneurysm. All patients were free of symptoms. No patients showed signs of heart failure during follow-up. Survival The cumulative survival is 91.7 ± 0.049% (Fig. 5). DISCUSSION No single technique is applicable to all patients; hence we adapted diverse strategies to deal with the specific problems of each case. Several pathological conditions such as aortic occlusive disease with long, narrow segments or multiple consecutive stenoses usually encountered as a congenital lesion, such as in mid-aortic syndrome [8], obviously benefit from extraanatomical bypass. Some patients with a recurrent coarctation have aortic arch hypoplasia rather than restenosis at the original site of the coarctation, which might be due to inadequate initial repair without addressing the arch hypoplasia or the inappropriate growth of the aortic arch [9]. The choice of extra-anatomical bypass and the surgical approach depended on the primary cardiovascular anatomy, the type of original repair, the site of the stenosis, the length of the Figure 2: 3D magnetic resonance imaging of stenosis of the proximal arch (A); ascending aorta to infrarenal aorta bypass (B). Figure 3: 3D magnetic resonance imaging of persistent postinterventional aortic arch hypoplasia (A); ascending to descending aorta bypass (B).

6 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery 405 CONGENITAL Figure 4: 3D magnetic resonance imaging of complex and multiple stenoses (A); ascending to infrarenal aortic bypass (B). Figure 5: Kaplan Meier curve showing cumulative survival. hypoplastic segments, the degree of tissue scarring from previous surgeries and the presence of an anastomotic aneurysm. Special considerations are given to the extent of the collateral circulation and the size and length of the graft, which are of utmost importance in growing children. Vijayanagar et al. [10] introduced extra-anatomical ascendingto-descending aortic bypass in 1980 to treat aortic coarctation. It eventually turned out to be an optimal alternative for complex repeat cases and in instances in which avoidance of in situ repair and CPB obviates nearly all intraoperative risks associated with extracorporeal circulation and deep hypothermia [5]. Over time, extra-anatomical bypass evolved not to be exclusive to ascending-to-descending aortic bypass; rather, extra-anatomical bypass grafting entails bypassing all diseased structures, thereby obviating the need for an anatomical repair, which is the path we have followed. The decision to perform extra-anatomical bypass with or without extracorporeal circulation in this series was based on the anatomical location of the coarctation, the length of the hypoplastic segment and the history of previous repair.we used circulatory support during reoperations in patients with post-coarctation anastomotic aneurysms, inadequate collaterals demonstrated by a drop in pressure to <50 mmhg in the aorta distal to the test clamp or a significant increase in pressure proximal to the test clamp. In this group, extracoporeal circulation was established through a left heart bypass between the left atrium and the descending aorta Alternatively, femoro-femoral bypass was used. The presence of dense fibrosis around the site of previous repair, a long-segment coarctation or poor collateral flow benefits from CPB, which allows the heart to be lifted to expose the descending thoracic aorta and reduces the risk of spinal cord ischaemia. Placing the extra-anatomical bypass through a left lateral thoracotomy, a median sternotomy, a combined median sternotomy and a laparotomy incision depends on the site of stenosis, the presence of heavy scarring and the presence of associated intracardiac anomalies. With coexistent intracardiac abnormalities, we approached the lesion through a median sternotomy with CPB, as was advocated by several other authors [11 13]. A long hypoplastic segment of aortic arch with recurrent aortic coarctation is best approached with a combined median sternotomy and laparotomy incision. In this setting, placement of extra-anatomical bypass between the ascending aorta and the infrarenal aorta is an excellent and safe technique. When the stenotic segment is confined to the mid- and distal aortic arch, an extra-anatomical bypass from the subclavian artery to the descending aorta or ascending aorta to the left subclavian artery, a left lateral thoracotomy approach offers an excellent exposure. A left subclavian-descending aortic bypass is relatively non-invasive, but a sufficiently large feeding artery is a prerequisite, which is frequent in aortic coarctation. In cases of anastomotic aneurysms or pseudoaneurysms, bypassing the diseased segment with either plication or closure of the aneurysm excludes the diseased aortic segment and excludes it from the circulation. Unfortunately, performing orthotopic aortic bypass as well as extra-anatomical bypass is prone to failure due to graft tension in the growing child. Hence, the choice of the graft, its size and the technique of placement play a vital role. When there is doubt about the somatic growth of the patient, the right pleural space can be opened to gain sufficient space to implant a graft long enough for an adult patient. An extra-anatomical bypass from the ascending distal abdominal aortic bypass graft using a single midline incision, from suprasternal notch to below the umbilicus, wherein the conduit is passed through a slit made in the centre

7 406 E.M. Delmo Walter et al. / Interactive CardioVascular and Thoracic Surgery of the diaphragm and brought around the right side of the heart for anastomosis to the right lateral side of the ascending aorta, was clearly suitable in young children, in view of subsequent growth. In small children <10 years of age, the largest calibre graft possible is used. One special concern is that, with somatic growth, tension increases on the graft, which may be a factor in the development of a pseudoaneurysm or of a patient graft mismatch. An important technical issue of extra-anatomical aortic bypass is the selection of a prosthetic graft of adequate size. We choose the size of the graft according to the diameter of the descending aorta (1:1 or slightly less). We prefer to use Dacron or ring-reinforced Dacron grafts to avoid compression by adjacent structures and late dilation of the graft, which also allow for subsequent somatic growth without compression of adjacent structures. We found no major limitations with the use of ascending to descending aortic extra-anatomical bypass, in contrast to the findings of Schoenhoff et al. [5] and other colleagues [14, 15], which are the age of the patient and the size of the aorta. These authors believe that this approach is not indicated in children and infants but should be discussed in adolescents and younger adults. Our experience in this series using this technique in growing children and in patients with a midaortic syndrome [8] showed no indication of short graft syndrome because the graft was given extra length in its curve through the chest and in the upper abdomen. The extra-anatomical bypass avoids manipulation of aortic segments with structurally altered wall and/or extensive collateral circulation, as typically seen in adults. Using extra-anatomical bypass in the repair of aortic arch coarctation likewise obviates hypothermic circulatory arrest. Furthermore, the necessity to dissect excessively scarred areas from previous operations or in patients with capacious arterial collateral circulation, is certainly circumvented. Lastly, in cases of isolated aortic arch coarctation, extra-anatomical bypass grafting can be performed without CPB [16]. In this series of patients in whom extra-anatomical bypass was performed, excellent operative and angiographic results have been observed. In accordance with other reports [5, 7, 15], we did not note perioperative deaths, coagulation problems, respiratory complications or neurological events. Preoperative hypertension was obviously influenced favourably by the operation. We are able to demonstrate that extraanatomical bypass is a valuable way to normalize blood pressure (at rest and during exercise), even in patients with long-standing hypertension, although 22.0% in our series (the older age group) still had mild/moderate hypertension and are taking antihypertensive medications during the follow-up period. Many studies [17 19] have shown that older age at repair is a predictor for persistent late systemic hypertension and that those older than 20 years at the time of the operation were more likely to have late hypertension than those operated on when they were between 5- and 19-years old. CONCLUSIONS This series demonstrates that extra-anatomical bypass is safe and achieves satisfactory long-term results in complex, recurrent arch coarctation and hypoplastic aortic arch. ACKNOWLEDGEMENTS We appreciate the assistance of Diana Kendall, Julia Stein, Christine Detschades, Carla Weber and Helge Haselbach. Conflict of interest: none declared. 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