Malposition of Stent a Rare Complication in Coarctation of Aorta Corrected with Extraanatomic Aortic Bypass

Mal-position of stent in coarctation of aorta is very rare but a major complication. Symptoms can worsen even more. We present here one such case where stenting done in some other institute in which we did an extra-anatomical bypass from ascending aorta to supracelial aorta successfully bypassing the coarct segment. This was an early approach without assistance of Cadiopulmonary (CP) Bypass. We conclude that this procedure should be done in centres where experienced operator and cardiac surgery back up is present. This was a good approach without assistance of CP Bypass.


Introduction
Coarctation of aorta (CoA) is a condition where the aorta is narrow in the area of insertion of ductus arteriosus.If the narrowing is severe enough left ventricle may not be strong enough to push blood through coarctation thus resulting in lack of blood to lower half of body.It's a common congential defect usually detected in childhood but can also present in adulthood.In developed countries, more adults are seen with coarctation than children and a prevalence of 5% -8% of all congenital heart disease is seen [1].Those presenting late in life have a higher prevalence of morbidity and late complication.ment.Here we present mal-position of stent in a case of CoA for which an extra-anatomical bypass from ascending aorta to supraceliac aorta was done without cardiopulmonary bypass (CPB) assistance.

Case Report
A 45-year male diagnosed having CoA (Figure 1

Discussion
Surgical repair of CoA can be achieved by several surgical techniques.With advancement of intervention cardiology balloon angioplasty either alone or along with stent is the preferred treatment modality [2].Studies have also shown stenting to have good results with no recoil of vessel wall or re-stenosis or aneurysm formation.Though rare but this procedure can cause major complication such as balloon rupture mal-position of stent, vascular complication of access site and stroke [3].
Our patient was not a good candidate for stent placement.Due to lack of expirence of the cardiologist he tried to stent the segment.But it was deployed distal to coarct segment, which led to worsening of the symptoms and created complication.No similar case is being reported till now.We did an extra anatomical bypass from ascending aorta to supraceliac artery to relive his symptoms.In 1977 Wukasch and colleagues [4] reported extra-anatomical bypass from ascending aorta to supraceliac bare portion of abdominal aorta.Advantage of this procedure is that the supraceliac bare area has less tributaries and least likely to be atherosclerotic thus less likely of bleeding, requires shortest course of graft, less bowl manipulation so less intestinal complication [5].

Connolly et al. described an extra anatomical bypass from ascending aorta to
descending aorta entirely through a sternotomy incision with CPB assistant.
Major limitation of this approach was bleeding from distal anastomosis because of poor access to distal thoracic aorta, CPB assistance, retraction of heart to cephalad position, difficult exposure in obese patient and barrel chest [6]

Conclusion
Mal-position of stent in treatment of CoA is a major complication and should be aggressively treated to prevent organ damage.So if possible stenting should be done in centers where experienced operators are available along with cardiac surgery facilities and a good preoperative evalution should be done.Better to do a ballondialatation before stenting so that proper size stent can be placed.The extra anatomical ascending aorta to abdominal aorta bypass graft approach is a safe procedure with no morbidity for this type of complication.Bypass to supraceliac abdominal aorta can be done without CPB assistance (therefore excluding the complication of CPB), preventing injury to phrenic and recurrent laryngeal nerve.Dissection around Distal thoracic aorta can be prevented which can lead to devastating hemorrhage due to multiple collaterals.Risk of ischemic injury to spinal cord is decreased.The main concern is only long incision, division of diaphragm, mobilization and manipulation of liver, esophageal injury.

Classification
Congenital heart disease in adult.
There are different methods describe for the treatment of CoA in adult including surgical or percutaneous balloon angioplasty with or without stent placement.Balloon angioplasty and stent placement is preferred mode of treat-N.Kisku et al.DOI: 10.4236/wjcs.2017.712019165 World Journal of Cardiovascular Surgery Figure 1.(a) CTA showing CoA before stenting; (b) CTA image after stenting.

Figure 2 .
Figure 2. Postoperative image.(a) Graft from ascending aorta passing through diaphragm lying side to right atrium; (b) CTA angiography after surgery showing good flow in graft and lower limb abdominal aorta.