Extra-Anatomical Bypass: A Surgical Option for Recurrent Aortic Coarctation

Background. Balloon aortoplasty with or without stenting is a less invasive alternative to open surgery for the management of recurrent isthmic coarctation. However, in patients with previous small size tube graft, an open surgical correction is mandatory and, in most cases, an anatomical aortic reconstruction is carried out. Methods. We present the case of a 48-year-old woman with recurrent aortic coarctation and systemic hypertension with systolic value around 190–200？mmHg and preoperative systolic pressure gradient 70？mmHg, submitted to an extra-anatomical bypass. Through a median sternotomy, an extra-anatomical bypass from ascending to descending aorta was performed. Results. No intra- or postoperative complications were observed. The postoperative pressure gradient was 10？mmHg and the systolic pressure ranged from 130 to 140？mmHg. Conclusion. The extra-anatomical bypass can be considered an effective and safe alternative to the anatomical aortic reconstruction in the cases with recurrent aortic coarctation unfit for endovascular treatment. 1. Introduction The incidence of isthmic coarctation of aorta is 6-7% of congenital heart disease [1]. Surgical treatment is performed in order to avoid serious heart complications. In fact not-operated patients early develop severe hypertension and heart failure. Surgical options in patients without other abnormalities include patch aortoplasty, subclavian flap angioplasty, combination of end-to-end anastomosis, tube graft. These interventions are carried out mostly in pediatric age and the incidence of recurrent coarctation ranges between 5 and 50% in relation to the diagnostic criteria [2]. It is the age of the first intervention that affects the recurrence frequency and less important are the various types of operations used. Undoubtedly the use of small-caliber prostheses in children or young patients increases the need for reoperation. In recent years, the balloon aortoplasty with or without stenting is a less invasive alternative to open surgery but can determine many complications and now this technique needs further experience to be validated [3]. In patients with recurrent coarctation the surgical treatment is also related to the onset of hypertension, ventricular hypertrophy, and dilation. The choice of the operation is dictated by the patient’s general conditions as well as by age and type of the previous surgical treatment. Balloon aortoplasty is not feasible in patients with previous tube graft interposition at their first operation. Open aortic reconstruction is often very difficult due to fibrous