Case 1
Previous Coarctation, representing with a gradient
The first question is what is the gradient ?
If greater than 50 mmHg at rest or upon exercise then intervention should probably take place. Previous repair makes surgical repair by redo left thoracotomy a high risk procedure. Aortic balloon angioplasty and stenting should be considered as possible interventions.
These patients have upper body hypertension and the possibility of coronary artery disease should not be forgotten, so angiography ? via the radial route should be considered. Coarctation is associated with a bicuspid aortic valve and dilatation of the ascending aorta. Each of these possibilities should be treated on their own merits.
Treatment options include:
Observe if recurrent gradient only mild even on exercise.
Redo Left thoracotomy - Difficult secondary to collaterals, adhesions and you are unable to address associated coronary artery disease, valvular or ascending aortic pathology.
Median sternotomy and extra anatomical bypass form ascending aorta to descending aorta via the posterior pericardium either via the right side of the heart or via the left side of the heart curving anterior to the main pulmonary artery. Associated coronary artery, valvular and ascending aortic pathology can be dealt with simultaneously.
3D reconstruction of extra anatomical graft
The following are still images of the above
