Alternative Approach for Selected High-Risk Patients with ISTHA: Concomitant Ascending-Descending Aortic Bypass Instead of Extensive Arch Surgery

Objectives: Aortic arch surgery is state of the art for treatment of adolescent patients with aortic isthmus stenosis (ISTHA). Nonetheless, multiple clinical conditions exist, which are prohibitive for extensive arch surgery. Herein we describe an alternative surgical approach.

Patients and Methods: Five patients with a mean age of 48 years were referred for CABG or valvular surgery. Preoperative CT-scans revealed a concomitant ISTHA (Fig. 1A/B). All patients were at high surgical risk due to relevant co-morbidities as represented by a mean EuroSCORE of 20.8% and a mean EuroSCORE II of 10.3%. For those reasons, an alternative surgical approach was chosen in alternative to concomitant extensive aortic arch surgery.

Results: Main surgery consisted of aortic valve replacement in four and CABG in one patient. For treatment of ISTHA, a bypass from the ascending to descending aorta using 10 up to 20mm Dacron prostheses (Fig. 1 C). For those purposes, the retrocardial pericardium was opened and the descending aorta exposed. After tangential clamping, the end-to-side anastomosis between the graft and descending aorta was performed using a 4.0 or 5.0 polypropylene suture. Subsequently, proximal end-to-side anastomosis with the ascending aorta was crafted. Mean skin-to-skin time was 174 minutes and all procedures were uneventful. After an uncomplicated postoperative course all patients could be discharged in the best of health. One-year follow-up revealed complete survival and running bypasses.

Conclusion: The reported approach is safe, convenient, quick to perform and thus a suitable way to reduce extend of surgery in selected high-risk patients presenting with concomitant ISTHA.