I am planning to operate 18 year old female with coarctation of aorta with isthmic hypoplasia, subclavian artery narrowed 90% at its origin and aortic diameter between SCA and left common carotid artery about 6mm. Gradient across coarct segment 85mm. Any suggestions regarding best surgical methodology of this patient.
DEAR DR MOHAMMED
MAY BE RESECTION OF THE COARCTED SEGMENT AND END TO END or tube graft ANASTOMOSIS WITH resection OF THE short STENOSED SUBCLAVIAN segment and end to end anastomosis.
If the arch hypoplasia is localised between the left carotid and the left subclavian artery maybe an interventional technique is also possible: stent distal aortic arch beyond the left carotid artery up to the isthmus and balloon dilate the stenotic subclavian through the stent struts. All depends a little bit on the length of the stenotic arch, the distance of the coarctation to the subclavian artery and the diameter of the coarctation (necessity for covered stent in isthmus or not). The surgical solution is of course a reasonable choice. Any image to share?
Thank you for the encouraging and scientific analytical responses.
I operated the patient today via left thoracotomy. Dissected all the arch vessels free anteriorly and looped LCC and SCA.Cannulated the proximal arch near BCA( secured by purse string ) which through a Y connector was connected to two cannulae for perfusion of the distal arch and LCC artery.Aorta cross clamped between LCC and BCA and 2 cms beyond ducts.Coarct segment resected including ductus area and the area of origin of SCA.LCC perfused with one cannula directly, the other perfusing the distal Ao.Aortic segment replaced with a 22 mm dacron graft.SCA reattached with a 8 mm dacron graft.
No gradient post surgery
Another option for these cases that we have made in several of them is the extra-anatomic correction. Through sternotomy grafting of the ascending aorta to the descending aorta supra-diafragamatica it stands, past the graft behind the inferior vena cava. In many cases without cardiopulmonary bypass or without aortic clamping.
See attahcment.
Regards.
Yes, That is an option if the surgeon deems the anatomical correction high risk to the patient. Another option being clamping the arch between BCA and LCC without using distal aortic or LCC antigrade perfusion. The latter is bein practised in paediatric patients with good results. I have reservations about the utilityof the latter technique in the adult patients owing to possible cerebral ischemia and spinal cord injury even though protection strategies are employed.