Abstract:

Background: article presents a case of 11-month-old baby weighing 6,590, with phenomena of circulatory decompensation, and non-standard hybrid intervention using retroperitoneal open access to the infrarenal aorta - stent implantation with the potential for increasing its diameter as the child grows

Materials and methods: the patient underwent examination - echocardiography (Echo-CG), multispiral computed tomography (MSCT), angiography Indication for the operation was the restenosis of the distal aortic anastomosis after the stage-by-stage surgical correction of hypoplastic left heart syndrome (Norwood procedure). This tactic was chosen taking into account the extremely high risk of re-surgery, as well as the impossibility of stent implantation with the potential for increasing the diameter through access to the femoral artery (body weight of the child is 6.6 kg). The patient underwent stenting of restenosis of the distal aortic anastomosis through retroperitoneal open access to the infrarenal aorta.

Results: good early postoperative period, against the background of disaggregant therapy (aspirin 5 mg/kg per day) and antibiotic therapy In control echocardiography (Echo-CG), the systolic pressure gradient in the stent implantation zone is 22 mm hg. The patient was discharged to an outpatient stage, followed by examination after 6 months and possible re-intervention (stent dilatation with a larger diameter balloon) as the pressure gradient rises as the child grows. Proposed hybrid approach in a child 11 months with a body weight of 6,590 kg allowed to avoid the risk of re-surgery in conditions of circulatory arrest and demonstrated a satisfactory angiographic and clinical result.

Conclusion: stenting of restenosis in distal aortic anastomosis using retroperitoneal access can be considered as a surgery of choice in specialized centers.

References

1.      Sakurai T., Rogers V., Stickley J. et. al. Single-center experience of arch reconstruction in the setting of Norwood operation. Ann.Thorac. Surg. 2012; 94:1534-1539.

2.      Pavlichev G.V., Podoksenov A.YU., Krivoshchekov E.V. Obstruction of the aortic artery after Norwood surgery in children with hypoplastic left heart syndrome. Patologiya krovoobrashcheniya i kardiohirurgiya. 2014;18(2):13-16 [In Russ].

3.      Bartram U., Granenfelder J., Van Praagh R. Causes of death after the modified Norwood procedure: a study of 122 postmortem cases. Eur. Vasc. Endovasc. Surg. 2017; 53(5):617-625.

4.      Vitanova K., Cleuziou J., Pabst von Ohain J. et. al. Recoarctation After Norwood I Procedure for Hypoplastic Left Heart Syndrome: Impact of Patch Material. Ann. Thorac. Surg. 2017; 103(2):617-621.

5.      Thomas P, Doyle M.D., William E. et al.Aortic obstructions in infants and children. Progress in Pediatric Cardiology. 1994; 3(1): 37-44.

6.      Rothman A., Galindo A., Evans W.N. et. al. Effectiveness and safety of balloon dilation of native aortic coarctation in premature neonates weighing <or = 2,500 grams. Am. Cardiol. 2010; 105:1176- 80.

7.      Atalay A., Pac A., Avci T.et. al. Histopathological evaluation of aortic coarctation after conventional balloon angioplasty in neonates. Cardiol. Young. 2018; 18:1-5.

8.      Dijkema E.J., Sieswerda G.T., Takken T.et. al. Longterm results of balloon angioplasty for native coarctation of the aorta in childhood in comparison with surgery. Eur. Cardiothorac. Surg. 2018 1; 53(1): 262-268.

9.      Fiore A.C., Ficher L.K., Schwartz T. et. al. Comparison of angioplasty and Surgery for Neonatal Aortic Coarctation. The society of the thoracic surgeons. 2005; 80:1659-65.

10.    Shaddy R., Boucek M., Sturtevant J., et.al. Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation.1993; 87:793-9.

11.    Attia I.M., Lababidi Z.A. Transumbilicalballon coarctation angioplasty. Am. Heart. 1988; 166:1623-4.

12.    Redington A.N., Booth P, Shore D.F., Rigby M.L., Primary ballon dilatation of coarctation of aorta. A multi-institutional study. Thor. Cardiovasc. Surg. 1994;108:841-51.

13.    Richard E.R., Gauvreau K., Moses H., et.al. Coarctation of the Aorta Stent Trial (COAST): Study design and rationale. Am. Heart. 2012; 164 (1): 7-13.

14.    Coulson J.D.,Vricella L.A., Alekyan B.G. Аlternative arterial and venous access for catheterization in children and infants. Endovaskulyarnaya hirurgiya. 2016;4: 24-39 [In Russ].

15.    Pursanov M.G., Svobodov A.A., Levchenko E.G. et. al. New Approach for Hybrid Stenting of the Aortic Arch in Low Weight Children. Structural Heart Disease. 2017;(3)5:147-151.

16.    Dorfer C., Standhardt H., Gruber A., et. al. Direct Percutaneous Puncture Approach versus Surgical Cutdiwon Technique for Intracranial Neuroendovascular Procedures: Technical Aspects. World Neurosur. 2012; 77(1): 192-200.

17.    Chakrabati S., Kenny D., Morgan G. et. al. Balloon expandable stent implantation for native and recurrent coarctation of the aorta - prospective computed tomography assessment of stent integrity, aneurysm formation and stenosis relief. Heart. 2010; 96 (15): 1212-6.

18.    Davenport J.J., Lam L., Whalen-Glass R., et. al. The successful use of alternative routes of vascular access for performing pediatric interventional cardiac catheterization. Cathet. Cardiovasc. Interv. 2008; 72 (3): 392-8.

19.    Sivanandam, S., Mackey-Bojack S.M., Moller J.H. Pathology of the aortic arch in hypoplastic left heart syndrome: surgical implications. PediatrCardiol. 2011; 32: 189-192.

20.    Hammel J.M., Duncan K.F., Danford D.A. et.al. Two- stage biventricular rehabilitation for critical aortic stenosis with severe left ventricular dysfunction. Eur. Cardiothorac. Surg. 2012; 1-6.

21.    Alekyan B.G. X-ray endovascular surgery. National Guidelines. M: Litterra. 2017; 1: 247-262 [In Russ].

22.    Feltes T.F., Bacha E., Beekman R.H. et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease. А scientific statement from the Am. Heart Association. Circulation. 2011: 7;123(22): 2607-52.

Abstract:

We had analyzed percutaneous coronary intervention (PCI) of non-standard complications - coronary artery dissection with extension on the eft main coronary artery (LMCA) and aorta. There was the coronary dissection of LMCA and aorta after left internal thoracic arteries and left anterior descending anastomosis (LIMA-LAD) balloon predilatation. Satisfactory angiographic result was achieved with blood flow TIMI III after stent implantation. In connection with the stable condition of the patient there was no endovascular or surgical treatment. The patient had stable hemodynamics in hospital period. The angiografic control was performed after 8 days. There was no coronary and aorta dissection and stent-thrombosis.

In conclusion in can be said that conservative tactics may be useful in a case of retrograde coronary and aorta dissection after LIMA-LAD stent mplantation.

References 

1.    Geraci A.R. Krishnaswami V., Selman M.W. Aorto-coronary dissection complicating coronary arteriography. J. Thorac. Cardiovasc. 2 Surg. 1973; 65: 695-698.

2.    Alfonso F. et al. Aortic dissection occurring during coronary angioplasty. Angiographic and transesophageal echocardiographic findings. Cathet. Cardiovasc. Diagn. 1997; 42: 412-415.

3.    Roberts W.C. Aortic dissection. Anatomy, consequences and causes. Am. Heart. J. 1981;101: 195-214.

4.    Erbel R. et al. Task Force on aortic dissection. European society of cardiology. Diagnosis and management of aortic dissection. Europ. Heart. J. 2001; 22: 1642-1681.

5.    Cigarroa J.E. et al. Diagnostic imaging in the evaluation of suspected aortic dissection. Old standards and new directions. N. Engl. J. Med. 1993; 328: 35-43.

6.    Kwan T. et al. Combined dissection of right coronary artery and right coronary cusp during coronary angioplasty. Cathet. Cardiovasc. Diagn. 1995; 35: 328-330.

7.    Perez-Castellano N. et al. Dissection of the        aortic sinus of Valsalva complicating coronary catheterization. Cause, mechanism, evolution, and management. Cathet. Cardiovasc. Diagn. 1998; 43: 273-279.

8.    Varma V. et al. Transesophageal echocardiographic demonstration of proximal right coronary artery dissection extending into the aortic root. Am. J. Cardiol. 1992; 123: 1055-1057.

9.    Hearne S.E. et al. Internal mammary artery graft angioplasty. Acute and long-term outcome. Cathet. Cardiovasc. Diagn. 1998; 44: 153-156.

10.  Wei-Chin Hung et al. LIMA graft interventions. Chang. Gung. Med. J.2007; 30 (3): 235-241

11.  Moussa I. et al. Effectiveness of clopidogrel and aspirin versus ticlopidine and aspirin in preventing stent thrombosis after coronary stent implantation. Circulation. 1999; 99: