HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiranya A. Rajasinghe Michael D. Black Doff B. McElhinney Frank L. Hanley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rajasinghe, H. A. Articles by Hanley, F. L. Search for Related Content PubMed PubMed Citation Articles by Rajasinghe, H. A. Articles by Hanley, F. L.

Ann Thorac Surg 1996;61:840-844
© 1996 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Coarctation Repair Using End-to-Side Anastomosis of Descending Aorta to Proximal Aortic Arch

Divisions of Cardiothoracic Surgery and Pediatric Cardiology, University of California, San Francisco, California

Accepted for publication November 3, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Recurrent aortic coarctation after primary operative repair in the neonate and small infant is seen most commonly within the first year of life. Inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been cited as important factors in early recurrence.

Methods. To address these issues, we have used a technique of coarctation resection and extended anastomosis of the descending aorta to the undersurface of the aortic arch. The salient features of this approach include extensive mobilization of the aortic arch and neck vessels, careful trimming of all ductal tissue, ligation of the isthmus just beyond the left subclavian artery, and end-to-side anastomosis of the descending aorta to a separate incision in the undersurface of the aortic arch proximal to all tubular hypoplasia. Between July 1992 and January 1995, 19 consecutive neonates (median age, 13 days) and 4 consecutive infants under 3 months of age (median age, 69 days) with a mean peak systolic upper to lower extremity resting gradient of 27.9 ± 16.9 mm Hg underwent repair of aortic coarctation and tubular hypoplasia of the arch. Other procedures performed at the time of repair included ligation of a patent ductus arteriosus (n = 19), pulmonary artery banding (n = 3), and closure of ventricular septal or atrial septal defect (n = 3).

Results. There were no perioperative deaths. Early postoperative complications included a recurrent laryngeal nerve injury and a transient focal tonic clonic seizure. There was one late death, after a subsequent intracardiac surgical procedure, at a median follow-up of 16 months (range, 1 to 29 months). Twenty-one of 22 late survivors were free of recurrent aortic coarctation by echocardiography findings and clinical examination, with a median upper to lower extremity gradient of 0 mm Hg. Reintervention for recurrent aortic coarctation was not required in any survivor.

Conclusions. The technique described herein completely removes all potentially abnormal tissue from the aorta, including ductal tissue and all tubular hypoplastic tissue proximal to the coarctation site.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The ideal operative repair for coarctation of the aorta and tubular hypoplasia of the aortic arch complex (COA) presenting in the neonatal period has not been found. Recurrent coarctation is a well-known and sometimes frequent complication regardless of the technique of repair and often requires operative reintervention or balloon angioplasty. Recurrent coarctation is seen most commonly within the first year of life and has been reported to occur in excess of 30% of cases [1, 2]. Inadequate removal of ductal tissue, failure to address tubular hypoplasia of the aortic arch, and suture line tension have been cited as important factors in early recurrence using standard repair techniques of resection and end-to-end anastomosis (and its modifications), subclavian flap arterioplasty, and patch aortoplasty [3–5]. Extensive experience over the past decade with the arterial switch operation for transposition of the great arteries indicates that circumferential aortic anastomoses in the neonate grow normally in virtually all cases, underscoring the principle that the most critical issue ensuring growth at the site of the neonatal aortic anastomosis is apposition of normal tissue. We have used a technique for coarctation repair that maximizes the chances of apposition of normal tissue at the anastomosis site and eliminates potentially abnormal tissue both proximal and distal to the anastomosis site.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The clinical records of all neonates and infants 3 months of age or younger undergoing aortic coarctation repair between July 1992 and January 1995 were studied retrospectively. In all patients, detailed follow-up was available, including postoperative blood pressure measurements in both arms and legs and two-dimensional echocardiography with Doppler assessment of pressure gradients across the coarctation repair site.

Definitions
AORTIC ARCH HYPOPLASIA.
The size of the aortic arch relative to that of the ascending aorta was assessed by echocardiography, and the arch diameter was confirmed by the operating surgeon. Hypoplasia of the proximal aortic arch was defined as a cross-sectional diameter of the aortic arch segment between the innominate artery and the left common carotid artery equal to or less than 60% of that of the ascending aorta. Hypoplasia of the distal aortic arch was judged to be present when the cross-sectional diameter of the arch segment between the left common carotid artery and the left subclavian artery was equal to or less than 50% of that of the ascending aorta [6].

RECURRENT AORTIC COARCTATION.
At the end of the operation, the pressures proximal and distal to the coarctation repair site were measured directly by a catheter pull-back method and recorded. The gradient between the two was defined as the immediate postrepair gradient. Recurrent coarctation was defined as the presence of a gradient of 20 mm Hg or greater at follow-up.

HYPERTENSION.
Patients were considered hypertensive when systolic blood pressure in the right arm exceeded the 95th percentile for blood pressure as defined by the American Task Force for Blood Pressure Control in Children [7].

Patient Population
Between July 1992 and January 1995, 19 consecutive neonates (median age, 13 days; range, 3 to 34 days) and 4 infants (median age, 69 days; range, 61 to 78 days) underwent operative repair of aortic coarctation complex. The median weight was 2.9 kg (range, 1.3 to 5.0 kg), and 20 patients (86.9%) had associated hypoplasia of the aortic arch. Associated intracardiac anomalies were present in 22 of 23 patients at the time of operation. Other morphologic lesions included patent ductus arteriosus in 19 (82.6%), atrial septal defect/patent foramen ovale in 15 (65.2%), ventricular septal defect in 15 (65.2%), Shone's complex in 5 (21.7%), complete atrioventricular canal defect in 1 (4.3%), and Taussig-Bing anomaly in 1 (4.3%). Two patients had hypertension, and 21.7% required inotropic agents. The preoperative upper to lower extremity peak systolic gradient at rest was 27.9 ± 16.9 mm Hg. A preoperative prostaglandin E₁ infusion was given in 15 patients (65.2%).

Operative Technique
All patients underwent the following repair. Using a left posterolateral thoracotomy through the third intercostal space, the aorta, ductus arteriosus, left subclavian artery, left carotid artery, and innominate artery were dissected and mobilized. Extensive mobilization of the aortic arch was accomplished by dissecting circumferentially at least to the base of the innominate artery; the descending aorta was mobilized to at least the second set of intercostal vessels (Fig 1A). Intercostal vessels were not ligated in the course of the dissection. An angled vascular occlusion clamp was placed across the distal transverse arch at the level of the undersurface of the aortic arch and opposite the origin of the innominate artery (Fig 1B), while unobstructed forward blood flow to the innominate artery was documented by a radial arterial line or pulse oximetry. This clamp isolated the left carotid and subclavian arteries as well. A second angled cross-clamp was placed across the descending aorta approximately 1.5 cm below the insertion of the ductus arteriosus and was used to control intercostal arteries if possible. Additional intercostal arteries were temporarily clipped.

View larger version (24K): [in this window] [in a new window]   Fig 1. . (A) Typical neonatal aortic coarctation with hypoplastic arch and isthmus and large patent ductus arteriosus as seen through a left posterior lateral thoracotomy. Dotted lines denote margins of the coarctation resection and arteriotomy incision along the undersurface of the aortic arch. (A. = artery.) (B) Ligation of the isthmus and ductus arteriosus and resection of discrete coarctation. Note placement of the proximal aortic occlusion clamp at the base of the innominate artery to include the left common carotid and left subclavian arteries. The descending aorta is widely mobilized to avoid tension on the suture lines without ligating any intercostal or collateral vessels. (C) Completed repair by end to side anastomosis of the descending aorta to the proximal aortic arch.

At the time of coarctation repair, additional surgical procedures included ligation of patent ductus arteriosus in 19 (82.6%), pulmonary artery banding in 3 (13%), and median sternotomy with closure of atrial septal defect, ventricular septal defect, or both defects in 1 patient (4.3%) each.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Mortality
A total of 23 consecutive neonates and infants underwent repair of aortic coarctation by ESAA. There were no perioperative deaths or any early deaths related to the initial operative repair of aortic coarctation. A single death occurred in an infant after a subsequent complex intracardiac surgical procedure, for an overall mortality rate of 4.3%. Twenty-two survivors were followed for a median duration of 16 months without any late deaths.

Morbidity
There were no intraoperative complications. No permanent neurologic sequelae were observed despite operative clamping of the left common carotid and left subclavian arteries for ESAA. The aortic cross-clamp time was 22.9 ± 11 minutes, and the peak upper to lower extremity systolic pressure difference in the operating room was 2.4 ± 4.8 mm Hg. There were no postoperative complications of intestinal ischemia, hemorrhage, or chylothorax. One transient focal tonic clonic seizure occurred postoperatively in a single patient; however, magnetic resonance imaging of the head failed to reveal any focal lesions, and the patient was subsequently discharged without anticonvulsant medication. No cases of paraplegia occurred. A recurrent left laryngeal nerve injury occurred in 1 patient with laryngomalacia, requiring tracheostomy.

Follow-Up
Detailed follow-up at a median duration of 16 months (range, 1 to 29 months) was obtained on 22 survivors from hospital records, referring pediatric cardiologists, and interviews with family members. During the follow-up period, 6 patients required a subsequent surgical procedure to repair intracardiac defects, and 1 patient underwent balloon aortic valvuloplasty. The success of coarctation repair was appraised by a combination of clinical examination (n = 17), two-dimensional Doppler echocardiography (n = 14), angiographic study (n = 3), or magnetic resonance imaging (n = 1).

Recurrent coarctation was diagnosed in only 1 infant, for an overall recoarctation rate of 4.5%. This patient left the operating room after COA repair with a 15-mm catheter pull-back gradient. Evaluation of the peak systolic pressure gradient in this patient at 6-month follow-up revealed a gradient of 28 mm Hg by clinical examination. Doppler echocardiographic examination demonstrated that the site of obstruction was at the level of the anastomosis, with good growth of the hypoplastic aortic arch. At 9-month follow-up, there has been no increase in the size of the gradient, and no angiographic studies have been performed in this patient. All other 21 survivors had upper to lower extremity gradients equal to 0 at follow-up, determined by some combination of physical examination, echocardiography, or cardiac catheterization. No reoperations or percutaneous transluminal balloon angioplasty procedures have been performed after the initial repair of coarctation.

Blood pressures were measured in the brachial arteries of 22 survivors using a sphygmomanometer, and hypertension was defined as sustained systolic and diastolic blood pressures greater than the 95th percentile for age. Before coarctation repair, 2 (8.9%) of the 23 patients were considered hypertensive. After ESAA, 1 (4.5%) of 22 survivors was hypertensive and required antihypertensive medication for blood pressure control at late follow-up. The postoperative peak systolic gradient was 0 mm Hg in this patient.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The various advantages and disadvantages of the commonly used techniques for repairing COA in the neonate must be measured in terms of outcome as judged by mortality rate, residual or recurrent gradients, and technique-related complications. In the present era, deaths are few using all techniques. The incidence of recurrent COA in neonates, however, remains substantial with each of the standard methods (recurrence rates vary from 7% to 25%), and there is little convincing evidence that any one method is superior [3, 5]. Apart from a probably higher incidence of aneurysm formation using synthetic patch aortoplasty [8, 9] and a present (but low) incidence of left arm dysfunction using the subclavian flap aortoplasty [10], it has been difficult thus far to make an objective distinction among the three commonly used techniques regarding technique-related complications: resection and end to end anastomosis, subclavian flap arterioplasty, and resection and extended end to end anastomosis. At present, we believe that ESAA, as described here, is the most appropriate procedure for a large number of neonates and infants with coarctation. This policy is based not only on a comparison of this technique with recent reports describing other techniques [5, 11–14], but also on the following considerations. First, the routine use of prostaglandin E₁ allows one to perform the operation on stable patients. This allows the necessary time at operation for careful and extensive mobilization of both the aortic arch and the distal descending aorta so that tension on the anastomosis can be avoided. Second, in extensive experience with the neonatal arterial switch operation for transposition of the great arteries [15], the circumferential suture line has proven to grow adequately when absorbable running sutures are used. This finding suggests that the circumferential suture line at the distal aortic arch will grow equally well if proper care is taken to resect all ductal tissue and resect or bypass all hypoplastic structures proximal to the discrete COA. Because ductal tissue may extend into the aorta not only distal to the insertion site of the ductus or ligamentum arteriosum (into the descending aorta) [16–19], but also proximally (into the isthmus) [16], the entire coarctation and isthmus, as well as more proximal arch hypoplasia, should be resected or bypassed. It is an attractive concept that excluding the abnormal tissue from the periductal aorta will minimize the likelihood of residual or recurrent obstruction. This is achieved using ESAA.

A technique similar to ESAA as described and illustrated in this report has been used to repair interrupted aortic arch and coarctation plus hypoplastic aortic arch through median sternotomy using cardiopulmonary bypass and circulatory arrest [20]. Although ESAA is applicable in the great majority of cases, flexibility must be emphasized, and the full repertoire of techniques should be considered in each individual case. For instance, in the presence of a ``bovine'' innominate trunk with hypoplasia of the distal aortic arch, median sternotomy, cardiopulmonary bypass, and circulatory arrest may be necessary to patch the undersurface of the aortic arch and distal part of the ascending aorta. Patch aortoplasty may be preferred in certain cases of discrete recoarctation that do not respond to balloon dilatation or in infants in poor clinical condition in whom the speed of the operation is of utmost importance. The subclavian flap aortoplasty may be the preferred technique in neonates with borderline left ventricular size in whom it is desirable to preserve temporarily the ductus arteriosus [21]. In addition, extended end-to-end repair [5, 11, 13] may be appropriate in older infants and children in whom the ductus has already closed and further constriction of the ductus is not an issue. These situations are uncommon, and we were able to use ESAA in all cases at our institution over a 2-year period.

Thus, ESAA is the procedure of choice for neonates and infants at our institution. Recurrent aortic coarctation has been identified in only 1 patient (4.5%). The observed gradient in this case was less than 30 mm Hg at 9 months of age. No reoperations or reinterventions have been performed thus far at a median follow-up of 16 months. Although we recognize that the follow-up period of our study is limited, a number of studies have shown that the majority of recoarctations occur within the first year of life regardless of the type of operative repair used [1, 20, 22, 23]. Thus, the results of ESAA when applied to neonates and young infants are compelling and compare favorably with those of other studies [1, 2, 12–14]. Further follow-up will be necessary to see whether the freedom from reintervention remains over an extended period and whether a favorable impact on systemic hypertension is achieved.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Presented at the Forty-fourth Annual Scientific Session of the American College of Cardiology, New Orleans, LA, March 19–22, 1995.

Address reprint requests to Dr Hanley, Division of Cardiothoracic Surgery, University of California, 505 Parnassus Ave, S-549, San Francisco, CA 94143.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Ziemer G, Jonas RA, Perry SB, Freed MD, Castaneda AR. Surgery for coarctation of the aorta in the neonate. Circulation 1986;74(Suppl 1):25–31.
2. Van Son JAM, Daniëls O, Vincent JG, van Lier HJJ, Lacquet LK. Appraisal of resection and end-to-end anastomosis for repair of coarctation of the aorta in infancy: preference for resection. Ann Thorac Surg 1989;48:496–502.[Abstract]
3. Jonas RA. Coarctation: do we need to resect ductal tissue? Ann Thorac Surg 1991;52:604–7.[Abstract]
4. Zannini L, Gargiulo G, Albanese SB, et al. Aortic coarctation with hypoplastic arch in neonates: a spectrum of anatomic lesions requiring different surgical options. Ann Thorac Surg 1993;56:288–94.[Abstract]
5. Lansman S, Shapiro JA, Schiller MS, et al. Extended aortic arch anastomosis for repair of coarctation in infancy. Circulation 1986;74(Suppl 1):37–41.
6. Moulaert AJ, Bruins CC, Oppenheimer-Dekker A. Anomalies of the aortic arch and ventricular septal defects. Circulation 1976;53:1011–5.[Abstract/Free Full Text]
7. Task Force for Blood Pressure Control in Children. Report of the second task force on blood pressure control in children. Pediatrics 1987;79:1–25.[Abstract/Free Full Text]
8. Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92:226–30.[Abstract]
9. DeSanto A, Bills RG, King H, Waller B, Brown JW. Pathogenesis of aneurysm formation opposite prosthetic patches used for coarctation repair. An experimental study. J Thorac Cardiovasc Surg 1987;94:720–3.[Abstract]
10. Van Son JAM, van Asten WNJC, van Lier HJJ, et al. Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy. Circulation 1990;81:996–1004.[Abstract/Free Full Text]
11. Vouhé PR, Trinquet F, Lecompte Y, et al. Aortic coarctation with hypoplastic aortic arch: results of extended end-to-end aortic arch anastomosis. J Thorac Cardiovasc Surg 1988;96:557–63.[Abstract]
12. Lacour-Gayet F, Bruniaux J, Serraf A, et al. Hypoplastic transverse arch and coarctation in neonates. Surgical reconstruction of the aortic arch: a study of sixty-six patients. J Thorac Cardiovasc Surg 1990;100:808–16.[Abstract]
13. Van Heurn LWE, Wong CM, Spiegelhalter DJ, et al. Surgical treatment of aortic coarctation in infants younger than three
14. Quaegebeur JM, Jonas RA, Weinberg AD, Blackstone EH, Kirklin JW. Outcomes in seriously ill neonates with coarctation of the aorta. A multiinstitutional study. J Thorac Cardiovasc Surg 1994;108:841–54.[Abstract/Free Full Text]
15. Castañeda AR, Jonas RA, Mayer JE Jr, Hanley FL. D-Transposition of the great arteries. In: Cardiac surgery of the neonate and infant. Philadelphia: Saunders, 1994:409–38.
16. Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosus. Histological study of 35 specimens. Br Heart J 1979;41:268–74.[Abstract/Free Full Text]
17. Elzenga NJ, Gittenberger-de Groot AC. Localised coarctation of the aorta. An age dependent spectrum. Br Heart J 1983;49:317–23.[Abstract/Free Full Text]
18. Russell GA, Berry PJ, Watterson K, Dhasmana JP, Wisheart JD. Patterns of ductal tissue in coarctation of the aorta in the first three months of life. J Thorac Cardiovasc Surg 1991;102:596–601.[Abstract]
19. Van Son JAM, Lacquet LK, Smedts F. Patterns of ductal tissue in coarctation of the aorta in early infancy. J Thorac Cardiovasc Surg 1993;105:368–9.[Medline]
20. Karl TR, Sano S, Brawn W, Mee RBB. Repair of hypoplastic or interrupted arch via sternotomy. J Thorac Cardiovasc Surg 1992;104:688–95.[Abstract]
21. Ungerleider RM. Is there a role for prosthetic patch aortoplasty in the repair of coarctation? Ann Thorac Surg 1991;52:601–3.
22. Beekman RH, Rocchini AP, Behrendt DM, Rosenthal A. Reoperation for coarctation of the aorta. Am J Cardiol 1981;48:1108–14.[Medline]
23. Merrill WH, Hoff SJ, Stewart JR, et al. Operative risk factors and durability of repair of coarctation of the aorta in the neonate. Ann Thorac Surg 1994;58:399–403.[Abstract]

This article has been cited by other articles:

				G. Gargiulo, C. P. Napoleone, E. Angeli, and G. Oppido Neonatal coarctation repair using extended end-to-end anastomosis MMCTS, May 23, 2008; 2008(0523): 2691. [Abstract] [Full Text] [PDF]

				H.-G. Lim, W.-H. Kim, W.-S. Jang, C. Lim, J. G. Kwak, C. Lee, S. W. Hwang, and C.-H. Lee One-stage total repair of aortic arch anomaly using regional perfusion Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 242 - 248. [Abstract] [Full Text] [PDF]

				J D R Thomson, A Mulpur, R Guerrero, Z Nagy, J L Gibbs, and K G Watterson Outcome after extended arch repair for aortic coarctation Heart, January 1, 2006; 92(1): 90 - 94. [Abstract] [Full Text] [PDF]

				G. E. Wright, C. A. Nowak, C. S. Goldberg, R. G. Ohye, E. L. Bove, and A. P. Rocchini Extended Resection and End-to-End Anastomosis for Aortic Coarctation in Infants: Results of a Tailored Surgical Approach Ann. Thorac. Surg., October 1, 2005; 80(4): 1453 - 1459. [Abstract] [Full Text] [PDF]

				A. E. Wood, H. Javadpour, D. Duff, P. Oslizlok, and K. Walsh Is extended arch aortoplasty the operation of choice for infant aortic coarctation? Results of 15 years' experience in 181 patients Ann. Thorac. Surg., April 1, 2004; 77(4): 1353 - 1358. [Abstract] [Full Text] [PDF]

				C. Lim, W.-H. Kim, S.-C. Kim, J.-W. Rhyu, M.-J. Baek, S.-S. Oh, C.-Y. Na, and C. W. Kim Aortic arch reconstruction using regional perfusion without circulatory arrest Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 149 - 155. [Abstract] [Full Text] [PDF]

				A. K. Younoszai, V. M. Reddy, F. L. Hanley, and M. M. Brook Intermediate term follow-up of the end-to-side aortic anastomosis for coarctation of the aorta Ann. Thorac. Surg., November 1, 2002; 74(5): 1631 - 1634. [Abstract] [Full Text] [PDF]

				R. Roussin, E. Belli, F. Lacour-Gayet, F. Godart, C. Rey, J. Bruniaux, C. Planche, and A. Serraf Aortic arch reconstruction with pulmonary autograft patch aortoplasty J. Thorac. Cardiovasc. Surg., March 1, 2002; 123(3): 443 - 450. [Abstract] [Full Text] [PDF]

				C. L. Backer and C. Mavroudis Congenital Heart Surgery Nomenclature and Database Project: patent ductus arteriosus, coarctation of the aorta, interrupted aortic arch Ann. Thorac. Surg., April 1, 2000; 69(4): S298 - 307. [Abstract] [Full Text] [PDF]

				J. A.M. van Son Repair of coarctation of the aorta Ann. Thorac. Surg., April 1, 1999; 67(4): 1212 - 1213. [Full Text] [PDF]

				D. A. Vitullo, S. Y. DeLeon, L. C. Graham, B. W. Eidem, P. T. Roughneen, J. J. Javorski, and F. Cetta Extended end-to-end repair and enlargement of the entire arch in complex coarctation Ann. Thorac. Surg., February 1, 1999; 67(2): 528 - 531. [Abstract] [Full Text] [PDF]

				P. A. Seirafi, K. G. Warner, R. L. Geggel, D. D. Payne, and R. J. Cleveland Repair of coarctation of the aorta during infancy minimizes the risk of late hypertension Ann. Thorac. Surg., October 1, 1998; 66(4): 1378 - 1382. [Abstract] [Full Text] [PDF]

				R. A. Brauner, H. Laks, D. C. Drinkwater Jr, F. Scholl, and S. McCaffery Multiple Left Heart Obstructions (Shone's Anomaly) With Mitral Valve Involvement: Long-Term Surgical Outcome Ann. Thorac. Surg., September 1, 1997; 64(3): 721 - 729. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiranya A. Rajasinghe Michael D. Black Doff B. McElhinney Frank L. Hanley Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rajasinghe, H. A. Articles by Hanley, F. L. Search for Related Content PubMed PubMed Citation Articles by Rajasinghe, H. A. Articles by Hanley, F. L.