Extra-anatomic aortic arch bypass for congenital anomaly; indications, techniques and outcome

The effect of extra-anatomic arch bypass operation remains to be defined, especially in congenital aortic arch anomalies. This study reviews our surgical experience and addresses its indications, techniques, and outcome. Between 1984 and 1996 eight patients underwent extra-anatomic arch bypass operations from the ascending aorta to the supra-celiac abdominal aorta through an extended midline sternotomy. The first group consisted of four pediatric patients (Group 1) who had undergone previous aortic arch repair during infancy and bypass operations were indicated for recurrent coarctation or the outgrowth of tube graft. The age at operation ranged between 4 and 12 years (Table 1). Partial cardiopulmonary bypass was applied during aortic clamp. Group 2 consisted of four adult patients (33 to 55 years old). One patient with aortic regurgitation and coarctation underwent aortic valve replacement and a bypass operation concomitantly under total cardiopulmonary bypass. The other three had aortic coarctation in which diagnoses were not confirmed until vascular evaluations after incidental cerebral hemorrhage or infarction. Cardio-pulmonary bypass was deferred because of cerebrovascular complications (Table 2). There were no operative deaths. Three patients complainted of mild abdominal pain for several days, but the recoveries were otherwise uneventful. The pressure gradient between the upper and lower extremities decreased both at rest (from 50 to 90 mmHg to less than 25 mmHg) and with exercise (from more than 100 mmHg to less than 40 mmHg). All patients received follow-up for 1 to 12 years; and all are in NYHA functional class I. In conclusion, extra-anatomic bypass operations appear to be a useful alternative in selected cases with aortic arch anomaly, including reintervention after aortic arch repair during infancy and in adults with cerebrovascular complications.