Delmo Walter Eva Maria, Javier Mariano Francisco Del Maria, Hetzer Roland
Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany.
Interact Cardiovasc Thorac Surg. 2017 Sep 1;25(3):400-406. doi: 10.1093/icvts/ivx115.
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.
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 40-120) mmHg.
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.
Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.
我们的目标是报告解剖外旁路手术用于纠正复杂、复发性主动脉缩窄和主动脉弓发育不全的选择方案、技术变异及长期结果。
1989年至2012年间，53例患者（平均年龄13.2±4.3岁，中位数11.6岁，范围9 - 23岁）患有复杂主动脉缩窄（n = 33；15例为长段主动脉弓发育不全）、复发性缩窄（n = 20；10例为吻合口假性动脉瘤），接受了解剖外旁路手术矫正，其中18例（股动脉旁路13例，左心旁路5例）使用体外循环，35例未使用体外循环，通过左外侧开胸手术（n = 48）以及联合正中胸骨切开术和正中剖腹术（n = 5）进行。是否使用体外循环的决定基于缩窄的解剖位置、发育不全的长度以及既往修复史。术前，静息时平均收缩压为130±30 mmHg，运动时为180±40 mmHg，平均压力阶差为80±11.6（范围40 - 120）mmHg。
各种解剖外旁路策略包括左锁骨下动脉至降主动脉（n = 38）、升主动脉至左锁骨下动脉（n = 3）、升主动脉至降主动脉（n = 4）、主动脉弓至降主动脉（n = 3）以及升主动脉至腹主动脉（n = 5）。根据计划移植血管近端和远端血管的直径选择移植血管大小（中位数18，范围10 - 26 mm）。未发生手术死亡、截瘫或腹部灌注不良。收缩压平均降低60±25 mmHg，无压力阶差。在平均18.3±3.7年的随访期间，未进行再次手术，未出现移植血管并发症或吻合口假性动脉瘤形成。7例（11.6%）患者服用抗高血压药物。无患者出现跛行，也无人因盗血现象出现体位性问题。
解剖外旁路手术安全、有效，可取得满意的长期效果。
