Posterior Pericardial Approach for Ascending
Aorta-to-Descending Aorta Bypass Through a
Median Sternotomy
Uzzi Izhar, MD, Hartzell V. Schaff, MD, Charles J. Mullany, MB, MS,
Richard C. Daly, MD, and Thomas A. Orszulak, MD
Section of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Background. Bypass grafting for repeat operation or
complex forms of descending aortic disease is an alter-
native approach to decrease potential complications of
anatomic repair.
Methods. Between December 1985 and February 1998,
17 patients (13 men, 4 women; mean age, 47.6 ⴞ 18.5
years) underwent ascending aorta-to-descending aorta
bypass through a median sternotomy and posterior peri-
cardial approach. Indications for operation were coarcta-
tion or recoarctation of aorta in 8 patients, Takayasu’s
aortitis in 2, prosthetic aortic valve stenosis associated
with coarctation of aorta, complex descending aortic arch
aneurysm, reoperation for chronic descending aortic dis-
section, long-segment stenosis of descending aorta, ac-
quired coarctation after repair of traumatic transection of
descending aorta, severe aortic atherosclerosis, and false
aneurysm of descending aorta after repair of coarctation
A dult patients with complex forms of descending
aortic disease remain a surgical challenge and have
a high risk of postoperative mortality and morbidity.
Surgical management may be further complicated when
associated cardiac defects require repair and there is no
consensus on the optimal approach. Indeed, anatomic
repair of the diseased segment of the descending aorta
may not be possible because of previous operations.
Various techniques of extraanatomic bypass grafting
from the ascending aorta have been described, including
methods in which the distal anastomosis is performed on
the descending thoracic aorta, the supraceliac abdominal
aorta, or the infrarenal abdominal aorta [1– 6].
Exposure of the descending thoracic aorta through a
median sternotomy and the posterior pericardium was
described by Vijayanagar and colleagues [7] and subse-
quently modified by Sweeney and associates [5], whose
alternate approach permits simultaneous intracardiac
repair when necessary. We report 17 consecutive patients
in whom the posterior pericardial approach to the de-
scending aorta was used and discuss the indications,
techniques, and results.
Accepted for publication Jan 11, 2000.
Address reprint requests to Dr Schaff, Section of Cardiovascular Surgery,
Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail:
schaff@mayo.edu.
© 2000 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc
in 1 patient each. Concomitant procedures were per-
formed in 12 patients.
Results. No early or late mortality has occurred. Fol-
low-up was 100% complete and extended to 12 years
(mean, 2.7 ⴞ 3.3 years). No late graft-related complica-
tions have occurred; 1 patient had successful repair of
perivalvular leak after mitral valve replacement, and 1
patient had replacement of lower descending and ab-
dominal aorta.
Conclusions. Exposure of the descending aorta through
the posterior pericardium for ascending aorta–
descending aorta bypass is a safe alternative and partic-
ularly useful when simultaneous intracardiac repair is
necessary.
(Ann Thorac Surg 2000;70:31–7)
© 2000 by The Society of Thoracic Surgeons
Patients and Methods
We reviewed the hospital records, operative notes, and
follow-up clinic records of 17 patients who underwent
ascending aorta-to-descending aorta bypass grafting
through a median sternotomy and posterior pericardial
approach between December 1985 and February 1998 at the
Mayo Medical Center. Demographic characteristics of the
patients are presented in Table 1. The ages of the 13 men
and 4 women ranged from 16 to 76 years (mean, 47.6 ⫾ 18.5
years). Preoperatively, all patients had echocardiography,
16 had aortography, and 12 had coronary angiography.
Eleven patients had previously undergone cardiac or tho-
racic aortic operations (Table 2). Concomitant procedures
were performed in 12 patients (Table 3).
Indications for Bypass Grafting
There were two general indications for the procedure.
The first indication was disease of the descending tho-
racic aorta and associated cardiac problems that required
repair through a median sternotomy (patients 1 to 12;
Table 3). The second indication was complex descending
aortic disease, in which extraanatomic bypass grafting
was chosen because of anticipated difficulties with ana-
tomical repair (patients 13 to 17; Table 3).
Preoperative diagnoses in group 1 included recurrent
coarctation of the aorta (n ⫽ 4), coarctation of the aorta
0003-4975/00/$20.00
PII S0003-4975(00)01481-8
32 IZHAR ET AL Ann Thorac Surg
POSTERIOR PERICARDIAL APPROACH 2000;70:31–7

Table 1. Demographic Characteristics of the Study Group (mean time, 120 ⫾ 65 minutes; range, 18 to 217 minutes)
was established after aortic and right atrial cannulation.
No. of
Patients Femoral artery cannulation was used in 1 patient. In all
Characteristic or Value % patients, the descending thoracic aorta was exposed
through the posterior pericardium by retracting the heart
Mean age (range, yr) 47.6 (16 –76)
cephalad and incising the pericardium longitudinally.
Sex
The descending aorta was controlled with a partially
Male 13 76.5
occluding vascular clamp, and the end-to-side graft-to-
Female 4
aorta anastomosis was made with continuous 4-0
Previous operation 11 65
polypropylene suture (Fig 1). The graft was led anterior
Cardiac 3a
to the esophagus and routed posterior to the inferior
Thoracic 10a
vena cava but anterior to the right inferior pulmonary
Hypertension 14 82.4
vein (Fig 2). The graft was then cut obliquely and anas-
CAD 4 23.5
tomosed to the right lateral aspect of the ascending aorta,
Preoperative NYHA functional
class
using a side-biting clamp.
I 11 64.7
In 5 patients in whom no additional cardiac procedures
II 4
were performed (patients 13 to 17; Table 3), the heart was
III 1
allowed to beat without aortic occlusion.
IV 1
In the 12 patients undergoing concomitant operations,
the cardiac procedures were accomplished after perform-
a
Two patients had more than 1 operation. ing the distal anastomosis of the graft to the descending
CAD ⫽ coronary artery disease; NYHA ⫽ New York Heart aorta. In 9 of these patients, the heart was arrested using
Association. cold crystalloid (n ⫽ 1) or cold blood (n ⫽ 8) cardioplegia,
antegrade (n ⫽ 9) or retrograde (n ⫽ 1) (mean cross-
clamp time, 56 ⫾ 33 minutes; range, 23 to 128 minutes). In
(n ⫽ 4), Takayasu’s aortitis (n ⫽ 1), complex descending
3 patients, we did not arrest the heart with cardioplegia.
aortic arch aneurysm (n ⫽ 1), severe aortic atherosclero-
The first patient (patient 10, Table 3) was a 75-year-old
sis (n ⫽ 1), and a false aneurysm of the descending aorta
man with a complex descending aortic arch aneurysm
at a site of previous graft repair of coarctation (n ⫽ 1).
associated with coronary artery disease (Fig 3). Aortic
Associated cardiac problems in this group included cor-
cross-clamping was avoided because of severe calcifica-
onary artery disease (n ⫽ 3), mitral valve regurgitation
tion of the ascending aorta. The distal coronary anasto-
(n ⫽ 3), aortic valve stenosis (n ⫽ 2), aortic valve regur-
mosis was performed with coronary perfusion, and prox-
gitation (n ⫽ 1), prosthetic aortic valve stenosis (n ⫽ 1),
imally the vein graft was anastomosed to the descending
and hypertrophic obstructive cardiomyopathy (n ⫽ 1).
aortic graft. The second patient (patient 9, Table 3) was a
The preoperative diagnoses in the second group (pa-
20-year-old woman with Takayasu’s aortitis that caused
tients 13 to 17; Table 3) included chronic descending
severe coarctation of the aortic arch and proximal de-
aortic dissection (n ⫽ 1), recoarctation of aorta (n ⫽ 1),
scending aorta and stenosis of the brachiocephalic ves-
Takayasu’s aortitis (n ⫽ 1), long-segment stenosis of the
sels. In this patient, the innominate and left common
descending aorta (n ⫽ 1), and acquired coarctation of
carotid arteries were reconstructed with a Dacron pros-
aorta after previous repair of traumatic transection of the
thesis fashioned as a Y graft and anastomosed proximally
descending aorta.
to the ascending aorta-to-descending aorta graft. The
Operative Technique third patient (patient 12, Table 3) was a 47-year-old
woman with a false aneurysm of the descending aorta at
A median sternotomy was performed in all patients.
a site of previous graft repair of coarctation of the aorta,
Hypothermic (16°C to 34°C) cardiopulmonary bypass
next to the origin of the left subclavian artery. In this
patient, the subclavian artery was reconstructed with a
Table 2. Previous Cardiac or Thoracic Operations Dacron bypass graft from the left common carotid artery.
Deep hypothermia and total circulatory arrest (mean
No. of
Operation Patients arrest time, 25 ⫾ 15 minutes; range, 10 to 49 minutes;
temperature, 16°C to 20°C) was used in 4 patients to
Repair of coarctation 7 facilitate construction of the distal anastomosis to the
Repair of descending aortic dissection 1 descending aorta (patients 1, 4, 13, 17; Table 3), and in 2
Repair of traumatic transection of 1 patients when replacing the aortic arch (patient 11, Table
descending aorta
3) and excluding a false aneurysm of the descending
AVR 1a
aorta (patient 12, Table 3).
Aortic valvotomy 1a
In 4 patients, the diseased segment of the descending
CABG 1
thoracic aorta was excluded from the circulation. The first
a
Same patient. patient (patient 13) was a 69-year-old man with a previ-
AVR ⫽ aortic valve replacement; CABG ⫽ coronary artery bypass ous repair of a descending aortic dissection using an
grafting. interposition tube graft in whom a false channel devel-
Ann Thorac Surg IZHAR ET AL 33
2000;70:31–7 POSTERIOR PERICARDIAL APPROACH

Table 3. Preoperative Diagnosis and Concomitant Procedures

Patient Age
No. (yr) Diagnosis Concomitant Procedure

1 15.8 Recoarctation, mitral regurgitation MVRe

2 59 Recoarctation, CAD CABG
3 39 Recoarctation, aortic regurgitation AVR
4 47 Recoarctation, aortic stenosis AVR
5 67 Coarctation, aortic stenosis, mitral regurgitation, HOCM AVR, MVRp, LV septal myectomy
6 45 Coarctation, mitral regurgitation MVRp
7 51 Coarctation, CAD CABG
8 25 Coarctation, prosthetic aortic valve stenosis AVR
9 20 Takayasu’s aortitis Reconstruction of arch great
vessels
10 75 Descending aortic arch aneurysm, CAD (Fig 3) CABG, LCCA–LSCA bypass graft
11 68 Ulcerative atherosclerosis (Fig 4) Replacement of ascending aorta
and aortic arch
12 47 False aneurysm, status postrepair of coarctation LCCA–LSCA bypass graft
13 69 Chronic descending aortic dissection
14 50 Recoarctation
15 56 Takayasu’s aortitis
16 51 Descending aorta atherosclerosis, severe stenosis
17 18 Acquired coarctation, status postrepair of traumatic
transection of descending aorta (Fig 5)

AVR ⫽ aortic valve replacement; CABG ⫽ coronary artery bypass grafting; CAD ⫽ coronary artery disease; HOCM ⫽ hypertrophic
obstructive cardiomyopathy; LCCA ⫽ left common carotid artery; LSCA ⫽ left subclavian artery; LV ⫽ left ventricle; MVRe ⫽ mitral valve
replacement; MVRp ⫽ mitral valve repair.

oped around the graft and extended beyond the distal
anastomosis into the abdomen. The aorta was divided at
the diaphragmatic hiatus, and the bypass graft was
anastomosed to the distal aorta; the proximal end of the
descending thoracic aorta was oversewn. The distal end
Fig 1. Exposure of the descending thoracic aorta through the poste-
rior pericardium. The heart is retracted by the assistant as partial
aortic clamping is applied to the descending aorta, and the distal
anastomosis is performed.
of the aortic arch was transected obliquely just distal to
the left subclavian artery. In this way, we interrupted the
aorta and excluded the aneurysmal descending aorta
from the circulation.
The second patient (patient 10, Table 3) was a 75-year-
old man with coronary artery disease and a 10-cm aneu-
rysm of the distal aortic arch originating just beneath the
orifice of the left subclavian artery (Fig 3). This patient
also had the additional anomaly of the left common
carotid artery originating from the innominate artery. We
first divided the left subclavian artery proximally and
performed a bypass graft, Hemashield 8 mm, from the
left common carotid (end-to-side) to the subclavian ar-
tery (end-to-side). After the ascending aorta-to-
descending aorta bypass graft had been completed, the
aneurysm was opened and excised. The proximal aortic
arch beneath the innominate artery was oversewn, as
was the origin of the left subclavian artery. The distal
aortic arch was near-normal in size, and we used a
Dacron patch to facilitate secure intraluminal closure; by
this method, we excluded the aneurysmal segment from
the circulation.
The third patient in whom we used this exclusion
technique was a 68-year-old man with recurrent periph-
eral embolization due to severe ulcerative atherosclerosis
of the ascending aorta, aortic arch, and descending tho-
racic aorta (patient 11, Table 3, Fig 4). The ascending aorta
and arch were excised and replaced with a 30-mm
Hemashield tube graft that was sewn proximally to the
aorta at the sinotubular junction and distally to the
brachiocephalic vessels. The descending thoracic aorta
34 IZHAR ET AL
POSTERIOR PERICARDIAL APPROACH
Fig 2. (Patient 7, Table 3.) In a patient with
coarctation of the aorta and coronary artery
disease, the course of the ascending aorta-to-
descending aorta bypass graft is shown. The
graft is led from the descending thoracic aorta
to the ascending aorta and routed posterior to
the inferior vena cava to the right lateral aspect
of the ascending aorta. A concomitant aorto-
coronary bypass graft was performed. (Asc ⫽
ascending; Des ⫽ descending; IMA ⫽ internal
mammary artery; IVC ⫽ inferior vena cava; R
⫽ right.)
was oversewn and excluded, and an ascending aorta-to-
descending aorta bypass graft was performed.
The fourth patient was a 47-year-old woman with a
thin false aneurysm of the descending aorta at the site of
a previous graft repair of coarctation of the aorta (patient
12, Table 3). After the ascending aorta-to-descending
aorta graft had been performed, using deep hypothermia
and total circulatory arrest, the distal aortic arch was
transected. The proximal aortic arch beneath the innom-
inate artery was oversewn. The distal end was the previ-
ous graft, which had disrupted at both the proximal and
distal suture line. Therefore, it was excised, and the
descending aorta was oversewn at the level of the hilum
of the lung.
Results
There was no hospital or late mortality. Perioperative
morbidity consisted of pneumonia (n ⫽ 1), mild renal
failure (n ⫽ 1), prolonged intubation (larger than 24 hour,
n ⫽ 1), and reoperation to control bleeding (n ⫽ 1). None
of the patients in whom deep hypothermia and total
circulatory arrest was used had neurologic deficit. Mean
hospital stay was 8.8 ⫾ 3.5 days (range, 5 to 17 days).
Follow-up was 100% complete and extended to 12
years (mean, 2.7 ⫾ 3.3 years). One patient who had a
concomitant mitral valve replacement underwent suc-
cessful repair of perivalvular leak. One patient with a
severe ulcerative atherosclerotic aorta and recurrent em-
bolization to the abdominal viscera and lower extremities
underwent resection of the lower thoracic and abdominal
aorta with aortic bilateral femoral bypass graft. There
were no late graft-related complications or reoperations.
All grafts are widely patent, as documented with fol-
low-up echocardiography. Three patients had postoper-
Ann Thorac Surg
2000;70:31–7
ative imaging studies: magnetic resonance imaging (pa-
tient 10, Table 3, Fig 3), aortography (patient 11, Table 3,
Fig 4), and computed tomography (patient 17, Table 3,
Fig 5).
Nine patients had a diagnosis of coarctation or reco-
arctation of the aorta, and all patients had been treated
for hypertension. At follow-up, only 1 patient continued
to take medication to control high blood pressure.
Comment
Various surgical procedures have been used for repair of
complex forms of descending aortic disease, including
anatomic repair and extraanatomic bypass grafting [1– 8].
Anatomic repair often requires extensive mobilization of
the aorta and control of collateral blood vessels; potential
complications include bleeding from adhesions, paren-
chymal lung injury, damage to the recurrent laryngeal or
phrenic nerves, chylothorax, and spinal cord ischemia [9].
Paraplegia remains the most feared complication, and
risk increases with prolonged aortic cross-clamp time
and older age [9].
In an early report by Edie and colleagues [1], 4 patients
with recurrent coarctation of the aorta underwent as-
cending aorta-to-descending aorta bypass grafting
through a combined left thoracotomy and median ster-
notomy. Later, Jacob and associates [10] reported satis-
factory long-term results in 10 patients who had been
operated on with the same technique. In a report of
operations for recurrent coarctation of the aorta,
Sweeney and associates [5] from the Texas Heart Insti-
tute described 16 patients who had bypass grafting
around the coarctation. In 12 patients, the graft was
inserted through a left thoracotomy, and in the other 4,
Ann Thorac Surg
2000;70:31–7
the graft from the ascending to descending aorta was
established through a median sternotomy.
When associated cardiac defects require repair, two
IZHAR ET AL 35
POSTERIOR PERICARDIAL APPROACH
Fig 3. (Patient 10, Table 3.) Complex descending aortic arch aneu-
rysm. (A) Preoperative magnetic resonance image (MRI) of the chest
(sagittal section). The aneurysm begins immediately distal to the
origin of the subclavian artery (short arrow). The right innominate
and left common carotid arteries have a common origin (long ar-
row). (B) Postoperative MRI of the chest demonstrated a widely
patent graft from descending thoracic aorta to ascending aorta (long
arrow). No flow is seen within the excluded aneurysm (short ar-
row).
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™
surgical approaches have been described: a one-stage
correction of both lesions simultaneously through a me-
dian sternotomy [5–7, 9, 11–15] and a two-stage repair
through a median sternotomy and thoracotomy [16].
Exposure of the descending thoracic aorta through the
posterior pericardium in performing ascending aorta-to-
descending aorta bypass grafting was described by Vi-
jayanagar and colleagues [7] in 1980 in an adult with
coarctation of the aorta associated with severe aortic
valve regurgitation. In this patient, the graft was placed
around the left margin of the heart, traversing the peri-
cardium and the left pleural cavity, anterior to the left
pulmonary hilum, and was anastomosed proximally to
the medial aspect of the ascending aorta. In 1983, Powell
and associates [14] described a modification of this tech-
nique in 4 patients in whom the graft was routed around
the right margin of the heart and anastomosed proxi-
mally to the right lateral aspect of the ascending aorta.
Since these initial descriptions, the posterior pericar-
dial approach to the descending aorta has been adopted
by other investigators, and 22 cases, in various modifica-
tions, have been reported in the English language liter-
ature [5–7, 9, 11–14]. We used this approach in 17 consec-
utive patients. We led the graft between the inferior vena
cava and the right inferior pulmonary vein, a route that
keeps the graft in a more posterior location without
compression of the right atrium and, thus, may protect
the prosthesis if sternal reentry is necessary.
This experience with the posterior pericardial ap-
proach to the descending aorta includes a heterogeneous
group of patients with complex forms of descending
aortic disease. Two-thirds of the patients had associated
cardiac or great vessel problems that were repaired
simultaneously, and 65% had previous cardiac or thoracic
operations.
Ten patients had native coarctation, recurrent coarcta-
tion, or acquired coarctation of the aorta. The reported
incidence of recurrent coarctation of the aorta is 5% to
10% [4], and no single method of repair is applicable in
all patients [3–5, 8]. When associated cardiac defects
require repair, a one-stage approach using cardiopulmo-
nary bypass and ascending aorta-to-descending aorta
bypass grafting through the posterior pericardium is a
safe technique that avoids the potential complications of
anatomic repair and reoperation and allows a concomi-
tant repair through the same incision.
In 1996, Pethig and associates [17] reported hemody-
namic instability in 2 patients early after combined aortic
valve replacement and extraanatomic bypass of coarctation
36 IZHAR ET AL
POSTERIOR PERICARDIAL APPROACH
Fig 4. (Patient 11, Table 3.) Severe ulcerative atherosclerosis. (A)
Contrast computed tomographic scan of the chest demonstrates a
large plaque along the lateral wall of the descending thoracic aorta
(arrow), with significant narrowing of the lumen. (B) Postoperative
aortography shows a patent ascending aorta-to-descending aorta
graft (long arrow). No flow is seen in the excluded proximal de-
scending thoracic aorta (short arrow).
of the aorta. They speculated that myocardial ischemia
developed when diastolic perfusion pressure was de-
Ann Thorac Surg
2000;70:31–7
Fig 5. (Patient 17, Table 3.) Coarctation of the aorta after repair of
traumatic transection of descending thoracic aorta. Postoperative spi-
ral computed tomographic scan of the chest, serially reconstructed
images. (A) Anterolateral view demonstrates the course of the as-
cending aorta-to-descending (Asc-Des) aorta bypass graft. (B) Pos-
terior view shows bypass graft and coarctation at the descending
(Des) thoracic aorta. (Ao ⫽ aortic; PA ⫽ pulmonary artery; SVC
⫽ superior vena cava.)
creased in severely hypertrophied hearts. We have not
observed this phenomenon in our 10 patients with the
diagnosis of coarctation or recoarctation of the aorta. An
alternative method is the two-stage repair of adult coarcta-
tion associated with congenital valvular disease [16].
Other indications for using this approach were Taka-
yasu’s disease, severe atherosclerosis, and complex de-
scending thoracic aortic aneurysm. Two patients with
Takayasu’s disease (patients 9 and 15) had stenotic le-
sions involving the descending thoracic aorta, aortic arch,
and arch great vessels, causing obstructive symptoms
and signs. In 1994, Robbs and colleagues [18] reviewed an
extensive experience with reconstructive surgery in 134
patients with Takayasu’s disease. Operative manage-
ment included reconstruction of the aortic arch, interpo-
Ann Thorac Surg
2000;70:31–7
sition grafts, or local bypass grafting, with good long-
term results. We elected to perform an ascending aorta-
to-descending aorta bypass graft in our 2 patients to
minimize risk and allow simultaneous reconstruction of
the brachiocephalic arteries.
Surgical approaches to symptomatic patients with ath-
erosclerotic disease of the aorta include endarterectomy,
resection and reconstruction, and extraanatomic bypass
grafting [19]. In our series, 1 patient underwent extraana-
tomic bypass grafting to prevent potential neurologic
complications when replacing a long segment of the
descending aorta. In the second patient, we elected to
replace the ascending aorta and the arch to exclude the
most severely diseased segment involving the descend-
ing aorta and to perform ascending aorta-to-descending
aorta bypass grafting, preventing a more extensive oper-
ation in an elderly patient.
Generally, aortic aneurysm should be treated by resec-
tion and graft replacement, but alternative methods are
necessary in some circumstances. In 3 of our patients
(patients 10, 12, and 13, Table 3)—1 with unusual primary
distal arch aneurysm, 1 with a false aneurysm at a site of
a previous graft repair of coarctation, and 1 with a false
channel after previous replacement of the descending
aorta—the extraanatomic bypass and the exclusion of the
diseased segment appeared to be a safer approach than
excision and graft replacement.
There are few reports concerning the long-term results
of bypass grafting for complex forms of descending aortic
disease. Potential long-term complications are graft nar-
rowing with thrombus and neointimal formation, infec-
tion, and development of false aneurysms. Our mean
follow-up was 2.7 years and extended up to 12 years;
although long-term follow-up is pending, none of the
patients required reoperation for graft-related complica-
tions. Other researchers have reported excellent results
for up to 10 years [5, 10]. Spiral computed tomographic
scanning has been very helpful in postoperative evalua-
tion and long-term follow-up [6]. Axial reconstruction
and multiplanar reformation reveal the full course of the
implanted graft (Fig 5).
In summary, no single technique is applicable to pa-
tients with these complex problems. However, exposure
of the descending aorta through the posterior pericar-
dium in performing ascending aorta-to-descending aorta
bypass grafting through a median sternotomy is a safe,
flexible method that is particularly useful when simulta-
neous intracardiac repair is required.
IZHAR ET AL 37
POSTERIOR PERICARDIAL APPROACH
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