Selection Strategy and Technical Variations of Extra-Anatomic Bypass in Surgical Management of Complex and Recurrent Aortic Coarctation and Hypoplastic Arch

Objective: We report the operative selection strategy and technical variations of extra-anatomic bypass to correct complex and recurrent aortic coarctation and hypoplastic aortic arch, and their long-term outcome.

Methods: Sixty patients (mean age: 29 ± 6.7 years) with complex aortic coarctation (n= 33) and recurrent coarctation (n= 27) underwent extra-anatomic bypass, either with or without extracorporeal circulation. The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, length of hypoplasia, and history of previous repair. Extra-anatomic bypass strategy was based on complexity of coarctation, sites of stenosis, and length of hypoplastic segment and included ascending aorta/aortic arch/left subclavian/left carotid to descending aorta, right subclavian artery to left carotid artery, left carotid to left subclavian artery, ascending aorta to left subclavian artery and ascending aorta to abdominal aorta. Preoperatively, mean systolic blood pressure was 130 ± 30 mm Hg at rest and 180 ± 40 mm Hg during exercise, with mean pressure gradient of 80 ± 11.6 (range: 40 – 120)mm Hg.

Results: There was no operative mortality, no incidence of paraplegia nor signs of neurological complications or abdominal malperfusion. Mean reduction in systolic blood pressure was 60 ± 25 mm Hg without any pressure gradient (p < 0.001). During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications, nor pseudoaneurysm formation. Seven (11.6%) had mild/moderate hypertension and are on antihypertensive medications. Late mortality is 8.3%.

Conclusions: This series demonstrates that extra-anatomic bypass is safe and achieves satisfactory long-term results in primary or recurrent aortic coarctation and in long segment aortic arch hypoplasia.