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A 44-year-old man reported recurrence of bilateral lower limb claudication and intractable cephalobrachial hypertension despite taking four antihypertensive drugs, having undergone repair of postsubclavian coarctation of the aorta 27 years ago. On evaluation, bilateral femoral pulses were feeble compared with the radial artery with discernible radiofemoral delay, gradient of 80 mm Hg, and ankle-brachial index of 0.55. Computed tomography angiography of the thoracic and abdominal aorta revealed tight stenosis of the graft at the proximal anastomosis to the left subclavian artery and kinking of the small polyester graft used earlier for repair of coarctation; there was also acquired atresia at the coarctation site (A). We performed ascending aorta to descending thoracic aorta (DTA) bypass through a pristine right thoracotomy, successfully using 16-mm Intergard woven graft (Intervascular, ZI Athelia, France). DTA poised on the left side of centra of thoracic vertebrae was dissected out carefully. Distal anastomosis was completed by suturing the graft using 4/0 polypropylene suture to aortotomy within exteriorized Lemole-Strong aortic clamp. Upon completion, 5/0 pledgetted suture was taken at the heel and toe of anastomosis and held on rubber shod to confirm secure anastomotic line while declamping and ensure perfect heamostasis, since anastomosis would be totally out of site retracting to left side of vertebral column upon releasing the aortic clamp. His postoperative recovery was uneventful. Computed tomography angiography, on the eighth postoperative day, visualized the intact repair and normally functioning ascending aorta to DTA bypass (B). At 1-year follow-up, his blood pressure was easily controlled with amlodipine 5 mg once daily, with well felt lower limb pulses and ankle-brachial index of 1.0.

Extra-anatomic ascending to descending thoracic aortic bypass for repair of adult aortic recoarctation