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Jump Graft Repair of Coarctation of the Aorta

This is a video showcasing a jump-graft repair for Coarctation of the aorta.

Coarctation of the aorta is one of the most well-known and documented congenital heart defects. Innovations in the field have led to a several options for surgical repair. However, patients with coarctation of the aorta remain at high risk for a number of morbidities including recoarctation aortic aneurysms and dilations, and sudden death. Our video showcases a jump graft repair, which is an underutilized approach for coarctation repair. Our goal is to educate others in the field on the proper technique and utility of this operation.

Objectives Coarctation of the aorta is one of the most well-known and documented congenital heart defects. Innovations in the field have led to a several options for surgical repair. However, patients with coarctation of the aorta remain at high risk for a number of morbidities including recoarctation aortic aneurysms and dilations, and sudden death. Our video showcases a jump graft repair, which is an underutilized approach for coarctation repair. Our goal is to educate others in the field on the proper technique and utility of this operation. Methods Lateral thoracotomy was used to obtain entry into the thoracic cavity through the fourth intercostal space. Cryoablation was then performed posteriorly, to the intercostal bundles above and below the incision. The parietal pleura was then dissected for exposure to the aorta and a vascular clamp placed on the distal arch. An incision was then made on the underside of the clamp and a woven synthetic graft was sewn onto the incision using an end to side technique. The tube graft was then closed with a vascular stapler to allow the distended graft to be placed in the anatomic position. The distal anastomosis site is marked. After clamping the graft, a bevel cut is made at the marked site. A separate clamp is then placed distally to the near interruption on the native aorta and an incision made on the underside. The distal graft is then sewn in, in an end to side fashion once again. The clamps are then removed, and both anastomotic sites evaluated for bleeding. After hemostasis is achieved the patient is closed in the usual fashion. Results Flow through the graft was confirmed with good hemodynamics above and below the graft. The patient had an uneventful post-operative course, had his chest tubes removed on post-op day 2, and was discharged on post-op day 6. Three month follow up saw a 20 mmHg decrease in the mean arterial pressure of the right arm and a return to normal activities. Conclusions Our video showcases a resoundingly successful repair of coarctation of the aorta through use of a jump graft. This video should serve to educate about this approach and showcase its utility. Additionally, there is often a delay between innovations in surgical technique and widespread implementation. There are a number of reasons for this, and a significant one is the difficulty of learning technique from a journal or paper. By showcasing this operation in a video form, we seek to bridge this gap in knowledge.
The patient was placed in a left lateral decubitus position with a single lumen endotracheal tube in place.  The skin incision is started at the level of the anterior axillary line over the fifth or sixth intercostal space. It is gently curved around the tip of the scapula and continued posteriorly along a line between the medial aspect of the scapula and the spine. It continued upwards to the level of T4 or even higher when necessary. The fourth intercostal space was identified and the endothoracic fascia and parietal pleura were opened.
Cryoablation was then performed on the posterior aspect of the incision and repeated two intercostal rib bundles above and below the incision. Recent studies have linked this technique to a reduction in post-operative narcotic use. The parietal pleura is then carefully removed from the aorta in preparation for the graft. After the aorta was mobilized superiorly and inferiorly the relevant anatomy was easily identifiable. An appropriately sized Satinsky clamp is placed on the distal arch, at the level of the left subclavian artery. An incision is made under the clamp and extended to accommodate the graft size. The proximal graft is then sewn in an end to side fashion with a running 5-0 polypropylene. Once the proximal graft is secured, aerosolized hemostatic is used prior to removal of the clamp. A stapler is then used to seal the graft distally. This technique allows the surgeon the freedom to move the graft into final position with the graft distended. The proximal clamp is then removed and the proximal site assessed for bleeding at the anastomosis. With the graft distended the surgeon marks the site for the distal anastomosis.  A clamp is placed proximally on the graft and a bevel cut is made at the marked location. A Satinsky clamp is placed distally to the near interruption. An incision is made under the clamp and extended to accommodate the distal graft. The distal graft is then sewn in, an end to side fashion using 5-0 polypropylene in a running fashion.  The distal clamp is then removed, and the anastomotic site is assessed for bleeding. The proximal clamp is then removed and both anastomotic sites are evaluated for bleeding. Once hemostasis is achieved the patient is closed in the usual fashion.
The patient was extubated on the table, is post operative course was uneventful, chest tubes were removed on post op day 2 And he was discharged on post op day 6.
Our video showcases a resoundingly successful repair of coarctation of the aorta through use of a jump graft. This video should serve to educate about this approach and showcase its utility. Additionally, there is often a delay between innovations in surgical technique and widespread implementation. There are a number of reasons for this, and a significant one is the difficulty of learning technique from a journal or paper. By showcasing this operation in a video form, we seek to bridge this gap in knowledge.
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Kim, Y. Y., Andrade, L., & Cook, S. C. (2020). Aortic Coarctation. Cardiology clinics, 38(3), 337–351. https://doi.org/10.1016/j.ccl.2020.04.003

 

Abbruzzese, P. A., & Aidala, E. (2007). Aortic coarctation: an overview. Journal of cardiovascular medicine (Hagerstown, Md.), 8(2), 123–128. https://doi.org/10.2459/01.JCM.0000260215.75535.64

 

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