Ascending; Aorta-Abdominal Aorta B6ass: Indications, Technique, and Report of 12 Patients

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1 Ascending; Aorta-Abdominal Aorta B6ass: Indications, Technique, and Report of 12 Patients Don C. Wukasch, M.D., Denton A. Cooley, M.D., Frank M. Sandiford, M.D., Gianantonio Nappi, M.D., and George J. Reul, Jr., M.D. ABSTRACT Use of!he supraceliac segment of the abdominal aorta for ascending aorta-abdominal aorta bypass (AAAAB) offers a new technique for management of certain difficult surgical problems. Since 1973, we have performed AAAAB in 12 patients: 4 with recurrent coarctation of the thoracic aorta; 4 with coarctation of the thoracic aorta and associated cardiac lesions requiring a concomitant intracardiac procedure; 2 with recurrent aortoiliac occlusive disease (AIOD); 1 with interruption of the aortic arch requiring concomitant pulmonary artery banding; and 1 with coarctation of the abdominal aorta. In 3 of these patients (2 with recurrent AIOD and 1 with coarctation of the abdominal aorta) the distal anastomosis was made to the distal abdominal aorta or femoral arteries. Ten patients (83.3%) experienced satisfactory results; 2 patients (16.6%) died. The technique of AAAAB provides a practical solution to complex situations in which previous procedures preclude a standard operative approach, or when necessary concomitant procedures would otherwise require a two-stage operation. Certain difficult operative problems preclude a standard surgical approach. Among these are recurrent coarctation of the thoracic aorta, coarctation of the thoracic aorta with associated intracardiac conditions requiring concomitant treatment, recurrent aortoiliac occlusive disease (AIOD) in which the infrarenal aorta is inaccessible, interruption of the aortic arch in infants with associated intracardiac defects, and coarctation of the abdominal aorta. Ingenious From the Division of Surgery, Texas Heart Institute of St Luke s Episcopal an d Texas Children s Hospitals, and the Department of Surgery, University of Texas Medical School, Houston, TX. Presented at the Twenty-third Annual Meeting of the Southern Thoracic Surgical Association, Acapulco, Mexico, Nov 4-6, Address reprint requests to Dr. Wukasch, Texas Heart Institute, PO Box 20345, Houston, TX methods using bypass procedures to manage such difficult situations have been described: axillofemoral bypass for AIOD (Blaisdell and Hall [ll, 1963); innominate artery-distal abdominal aorta bypass for coarctation (Inokuchi and colleagues [51, 1971); descending thoracic aorta-femoral artery bypass for AIOD (Nunn and Kamal [71, 1972); and aortic arch or proximal descending thoracic aorta-distal descending thoracic aorta bypass for recurrent coarctation (Weldon and associates [ill, 1973). The concept of utilizing the ascending aorta for proximal anastomomis for such bypass grafts was reported by Schumacker and co-workers [9] in 1968 for a patient with mycotic aneurysm following repair of coarctation of the thoracic aorta in which a graft was brought from the ascending aorta to the infrarenal abdominal aorta. (The patient died of complications of the primary disease several weeks postoperatively.*) In 1972 Robinson and colleagues [81 reported treating a dissecting descending thoracic aortic aneurysm with a graft from the ascending aorta to the infrarenal abdominal aorta. A successful bypass graft from the ascending aorta to the infrarenal abdominal aorta for coarctation of the thoracic aorta was reported by Siderys and associates [lo] in 1974 in a patient with coarctation of the thoracic aorta that was inaccessible because of a fibrothorax. In 1974, Frantz and associates [4] reported a case in which ascending aortafemoral artery bypass was performed in a patient with severe AIOD. More recently, Liotta and co-workers [6] reported a patient with an infected pseudoaneurysm following operative treatment of a coarctation of the thoracic aorta. In each of these reports of ascending aortaabdominal aorta bypass (AAAAB), the distal *Shumacker HB Jr: Personal communication [lo]. 442

2 443 Wukasch et al: Ascending Aorta-Abdominal Aorta Bypass anastomosis was placed into the distal (infrarenal) abdominal aorta. During the past three years, we have used a modification of the concept of AAAAB. With this technique the distal end of the ascending aortic graft is anastomosed end-to-side to the supraceliac bare area (SBA) of the abdominal aorta just below the level of the diaphragm. This report describes application of this technique [31 in 9 patients. Three additional patients are described in whom the distal anastomosis was made to either the infrarenal abdominal aorta or the femoral arteries. Clinical Material Since July 10, 1973, 12 patients (6 male, 6 female) have undergone ascending aorta-abdominal aorta (or femoral artery) bypass at the Texas Heart Institute (Table 1). Ages ranged from 14 days to 49 years, with an average age of 28 years. The indications for performing this procedure are shown in Table 2. The categories of anatomical lesions are depicted in Figure 1. Operative Procedures A standard median sternotomy incision is made and extended caudad through the midline abdominal fascia to the level of the umbilicus if the SBA is to be the site of the distal anastomosis. The ascending aorta is exposed by dividing the mediastinal tissues, leaving the pericardium intact. The transverse colon and stomach are retracted downward through the abdominal incision and the liver is mobilized to the right by dividing the triangular ligament of the left lobe. The right crus of the diaphragm is incised, exposing a generous portion of aorta (SBA) proximal to the celiac axis (Fig 2A). A partially occluding clamp is placed on the ascending aorta, and a 16 or 18 mm diameter, low porosity, woven Dacron graft" is anastomosed end-toside to the aorta. The graft is passed to the right of the right atrium, ventral to the inferior vena cava, and then passed through a T-shaped opening made in the fibrous portion of the diaphragm. The supraceliac portion of the abdominal aorta is clamped with either a partially occluding clamp or two vascular clamps (Fig 2B), and the distal end of the graft is anastomosed to the aorta end-to-side with a continuous suture of 4-0 polyester [3]. This technique, used in a 43-year-old man with recurrent coarctation of the thoracic aorta (Patient 12, Table l), is shown in Figure 3. The treatment of patients with coarctation of the thoracic aorta associated with acquired car- *Meadox Medicals, PO Box 530, Oakland, NJ Table 1. Experience with Ascending Aorta-Abdominal Aorta Bypass (AAAAB) Patient No., Age (yd. and Sex Date Diagnosis Procedure Result 1. 14, M 2. 15, M 3. 41, F 4. 43, M 5 14 days, F 6. 17, F 7. 33, M 8. 11, F 9 34.M /11/ /6/ Coarctation, abdominal aorta Recurrent coarctation, thoracic aorta Recurrent aortoiliac occlusive disease Recurrent coarctation, thoracic aorta Interruption of aortic arch, ventricular septa1 defect, patent ductus arteriosus Coarctation, thoracic aorta and mitral insufficiency Coarctation, thoracic aorta and aortic stenosrs Recurrent coarctation, thoracic aorta Coarctation, thoracic aorta and mitral insufficiency AAAAR AAAAB and bypass to left subclavian artery Ascending aorta-deep femoral artery bypass AAAAB AAAAR and pulmonary artery banding AAAAR and mitral valve replacement AAAAR and aortic valve replacement AAAAR AAAAB and mitral annuloplasty 10 38, F Recurrent aortoiliac occlusive disease Ascending aorta-femoral artery bypass , F Coarctation, thoracic aorta, aortic AAAAR, aortic valve replacement, stenosis, aneurysm of ascending aorta, idiopathic hypertrophic subaortic resection of aneurysm ascending aorta, and excision of myocardium stenosis , M Recurrent coarctation, thoracic aorta AAAAR Died 2 mo postop following thrombosis of graft and pulmonary embolus Died 2 days postop secondary to congestive heart failure (postop hemorrhage; required reexploration) (postop transient cerebrovascular accident secondary to air embolus)

3 444 The Annals of Thoracic Surgery Vol 23 No 5 May 1977 Table 2. Indications jor Ascending Aorta-Abdominal Aorta Bypass in 12 Patients Indications No. of Patients Recurrent coarctation of thoracic 4 aorta Coarctation of aorta with asso- 4 ciated intracardiac lesions Recurrent aortoiliac occlusive 2 disease Interruption of aortic arch in 1 infants Coarctation of abdominal aorta 1 diac lesions may tle demonstrated by the technique [2] used in a 49-year-old woman (Patient 11, Table 1) who had coarctation of the thoracic aorta, calcific aortic stenosis, an aneurysm of the ascending thoracic aorta, and idiopathic hypertrophic subaortic stenosis (IHSS) (Fig 4). On July 17,1976, following institution of temporary cardiopulmonary bypass, the patient underwent resection of the aneurysm of the ascending aorta and replacement with a 26 mm diameter, low porosity, woven Dacron graft; aortic valve replacement with if low-profile, biconical disc, full-orifice Cooley-Cutter* prosthetic valve; resection of the "hypertroph" of the IHSS; and bypass grafting Erom the ascending aortic graft to the supraceliac portion of the abdominal aorta using a 16 mm diameter, woven, low porosity Dacron graft (Fig 5). The patient experienced several episodes of tachyarrhythmia postoperatively, and she responded satisfactorily to medical management. Postoperative cineangiograms showed satisfactory function of the graft and no kinking or impingement by adjacent organs. She was discharged from the hospital in good condition 16 days postoperatively. The technique of AAAAB was also used for treatment of coarctation of the abdominal aorta in a 14-year-old boy (Patient 1, Table 1; Fig 1, d). In this instance, with stenosis both above and below the renal arteries, a graft was brought from the ascending aorta through the gastrohepatic ligament into the retroperitoneum and anastomosed to the abdominal aorta at the *Cutter Laboratories, Biomedical Device Division, 7380 Conway Ct, San Diego, CA Fig 1. Anatomical lesions for which AAAAB was performed: (a) recurrent coarctation of thoracic aorta; (b) coarctation of thoracicaorta with associated anomalies-1, congenital aortic stenosis or mitral insufficiency, 2, acquired aorticstenosis and aneurysm of ascending aorta; (c) interrupted aortic arch with associated in tracardiac defects; (d) coarctation of abdominal aorta; and (e) recurrent aortoiliac occlusive disease with extensive fibrosis. level of the renal arteries. A second graft was then anastomosed to the previous graft above and to the distal abdominal aorta below (Fig 6). In patients with recurrent AIOD who have undergone multiple previous procedures, AAAAB can be used to avoid approaching an inaccessible abdominal aorta (Fig 1, e). In a 38- year-old woman (Patient 10, Table 1) a graft was brought from the ascending aorta through the I i

4 445 Wukasch et al: Ascending Aorta-Abdominal Aorta Bypass Fig2. (A) Exposure ofsupraccliac aorta. Dottedline indicates lirie of iricisiori in riglit crusof diapliragni. (B) Technique ofclnnipirigstrpracclinc aorta at site of distal arinstoniosis. Fig3. (A) Preoperative aortograni demonstrating recurretit coarctatiori of thoracic aorta in 43-year-old inan (Patient 12, Table 1). (B) Graft froniasceiidirig aorta toabdominalaorta in Patient 12.

5 446 The Annals of Thoracic Surgery Vol 23 No 5 May 1977 Fig 4. Anatomical lesions in Patient 2 2, demonstrating (a) calcific aortic valve stenosis, (b) aneurysm of ascending aorta, (c) coarctation of descending thoracic clorta, and (d) idiopathic hypertrophic subaor ic stenosis. Preoperative blood pressures were mm Hg in the left ventricle, mm Hg in the ascending aorta, and mm Hg in theabdominalaorta. diaphragm and gastrohepatic ligament into the retroperitoneum and anastomosed distally to both common femoral arteries (Fig 7). Results Of the 12 patients in our series, 10 experienced satisfactory results, and 2 patients died. Causes of death were congestive heart failure in a 14- day-old infant (Patient 5, Table 1) who had complete interrupticin of the aortic arch with an associated ventricular septa1 defect (VSD) and a patent ductus arteriosus (PDA); and a pulmonary embolus two months postoperatively in a 41-year-old woman (Patient 3, Table 1) with severe coronary artery occlusive disease following thrombosis of the graft to both deep femoral arteries. In 2 patients, nonfatal complications occurred: a postoperative hemorrhage requiring Fig5. Postoperative reconstruction of operation done on Patient 11 (Fig4), demonstrating myomectomy, aortic valve replacement, resection and Dacrongraft replacement of ascending aortic aneurysm, and ascending aorta-abdominal aorta bypass graft. Postoperative blood pressures were mm Hg in the ascending aorta and mm Hg in the abdominal aorta. reexploration in a 17-year-old girl (Patient 6, Table 1) who underwent AAAAB and mitral valve replacement; and a transient cerebrovascular accident, apparently from an air embolus, in a 33-year-old man (Patient 7, Table 1) who underwent AAAAB and aortic valve replacement. Comment The use of the ascending aorta for proximal anastomosis for bypassing complex lesions has been described previously [4, 6, 8-10]. Use of the supraceliac bare area (SBA) of the proximal abdominal aorta appears to offer a new and practical solution to an otherwise difficult operation. A number of advantages appear to make the SBA the site of choice for the distal anastomosis in

6 447 Wukasch et al: Ascending Aorta-Abdominal Aorta Bypass Fig 6. Technique of treatment of coarctation of abdominalaorta(patient I, Table 1) by AAAAB with distal anastomoses to abdominalaorta at leuelof renal arteries and bifurcation. AAAAB. First, this segment of aorta is of adequate length to accommodate the graft and is the portion of aorta least likely to contain atherosclerotic disease. Second, use of this site offers the shortest route for course of the graft, and it minimizes the threat of intestinal complications from erosion or obstruction of adjacent organs, a potential problem when using a longer graft that traverses the peritoneal cavity. Third, this technique allows for a shorter abdominal incision and less manipulation of bowel, resulting in less postoperative ileus. Finally, the aorta Fig 7. AAAAB in Patient 10,70ho had recurrent AIOD, with distalanastomosis to both common femoral arteries. The patient had previously undergone an aortofemoral bypass which had become thrombosed. An initial attempt was made to place a new graft to the infrarenalabdominalaorta, but severe disease in this area precluded satisfactory anastomosis. Therefore the abdominal incision 70as extended to a median sternotomy and AAAAB was performed.

7 448 The Annals of Thoracic Surgery VoI 23 No 5 May 1977 at this site is relatively free of tributaries, lessening the potential of spinal cord devascularization injuries commonly associated with management of recurrent coarctation of the thoracic aorta. References Blaisdell FW, Hall AD: Axillofemoral artery bypass for lower extremity ischemia. Surgery 54:563, 1963 Cooley DA, Nappi G, Ott DA, et al: One stage repair of multiple lesions of the left ventricle and aorta. Cardiovascular Diseases, Bull Texas Heart Inst 3:289, 1976 Cooley DA, Norman JC: Techniques in Cardiac Surgery. Houston, Texas Medical Press, 1975, pp Frantz SL, Kaplitt MJ, Beil AR, et al: Ascending aorta-bilateral femoral artery bypass for the totally occluded infrarenal abdominal aorta. Surgery 75:471, 197' Inokuchi K, Kusaba A, Ono K, et al: Innominoabdominal aortic bypass graft: a safe alternative for coarctation of aorta. Jpn J Surg 1:161, 1971 Liotta D, Donato FO, Bertolozzi E: Treatment of staphylococcal aortic pseudoaneurysm employing ascending aorta-abdominal aortic bypass graft. Chest (in press) Nunn DB, Kamal MA: Bypass grafting from the thoracic aorta to femoral arteries for high aortoiliac occlusive disease. Surgery 72:749, 1972 Robinson G, Siegelman S, Attai L: Recurrent dissecting aneurysm of aorta. NY State J Med , 1972 Shumacker HB Jr, King H, Nahrwold DL, et al: Coarctation of the aorta. Curr Probl Surg, 1968, pp Siderys H, Graffs R, Hallbrook H, et al: A technique for management of inaccessible coarctation of the aorta. J Thorac Cardiovasc Surg 67:568,1974 Weldon CS, Hartman AF, Steinhoff NG, et al: A simple, safe and rapid technique for the management of recurrent coarctation of the aorta. Ann Surg 15:510, 1973