A 37-year-old female patient was admitted with
complaints of back pain. On physical examination, her
blood pressure (BP) measurements were 123/97 mmHg
and 114/92 mmHg at her right and left arm, while
84/67 mmHg and 82/65 mmHg at her right and left
ankle. Chest X-ray showed a calcified mass and then
transthoracic echocardiography was performed. On
echocardiography, aortic coarctation with 38 mmHg peak gradient and aneurysm of the descending
aorta was detected. Thoraco-abdominal computed
tomography angiography, coronary angiography, and
aortography was performed (Figure
3,
4). According
to the Ishimaru classification, aortic coarctation and
descending aortic aneurysm localized zone 2 and
zone 3 (Figure
1) was identified (Figure
2). Bilateral
carotid and vertebral artery Doppler ultrasonography
showed no pathology.
Figure 1: Ishimaru classification.
Figure 2: Preoperative thoraco-abdominal computed
tomography angiography
Figure 3: Preoperative three dimensional computed
tomography angiography.
Figure 4: Preoperative aortography.
Surgery was performed under general anesthesia
with cerebral oximetry monitoring by nearinfrared
reflectance spectroscopy (NIRS). Heparin
administrated to maintain activated clotting time
(ACT) over 300 s. Median sternotomy was performed
and innominate vein agenesis was observed. An
additional anatomical variations or venous anomaly
was not detected. Truncus brachiocephalicus
and left common carotid artery were explored.
The left subclavian artery was located in the
aneurysm site. Aorta-to-left common carotid and
aorta-to-truncus brachiocephalicus bypass operations were performed with side clamping by using 7/14 mm
Y-shaped Dacron graft without cardiopulmonary
bypass (Figure 5). Zone of the stent will be placed
on the ascending aorta were marked with wire of
pacemaker.
Figure 5: Aorta-to-left common carotid and
aorta-to-truncus brakiosefalikus bypass.
At the same session, left common carotid-to-left
subclavian artery bypass surgery was also performed.
The left femoral artery was explored before the end of the operation for TEVAR. Artery calibration viewed
approximately 10 mm. The patient after surgical
procedures was taken to angiography unit. A 20 mm
self-expandable nitinol stent (E-XL Endoluminal
Aortic Stent Prosthesis 20x30 mm, JOTEC GmbH,
Hechingen, Germany) was deployed across the
coarctation and aneurysm site without previous balloon
dilatation procedure. The proximal end of the stent to
the ascending aorta and distal end of the stent was
placed to distal zone of coarctation site (Figures 6, 7).
Figure 6: Postoperative aortography.
Figure 7: Postoperive computed tomography
No further balloon dilatation was done immediately
after the stent deployment to avoid unnecessary tissue
injury. There was no endoleak at the end of the
procedure and the patient was taken to the intensive
care unit. The patient was discharged at the sixth postoperative day. At two months and every six months,
follow-up was scheduled and no endoleak was observed.
The BP measurement of four limbs evaluated (Table 1).
Table 1: Blood pressures (systolic/mean/diastolic, mmHg) of four limbs
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}
){kind=link}