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Ann Thorac Surg 1996;61:1262-1264
© 1996 The Society of Thoracic Surgeons

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Case Report

Late Aneurysm After Subclavian Flap Aortoplasty for Coarctation of the Aorta

Departments of Cardiovascular Surgery and Pediatrics, Okayama University Medical School, Okayama, Japan

Accepted for publication September 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Late aneurysms are common after repair of coarctation of the aorta by prosthetic patch aortoplasty but are rare after subclavian flap aortoplasty. We present the case of a 14-year-old boy who underwent a grafting procedure for a descending thoracic aortic aneurysm after subclavian flap aortoplasty for coarctation of the aorta when he was 2 years old. This is the fifth report of late aneurysm formation after subclavian flap aortoplasty.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Late aneurysm of the descending thoracic aorta is a well-known postoperative complication after repair of coarctation of the aorta. Almost all such aneurysms occur after prosthetic patch aortoplasty [1, 2]. We describe the case of a patient who underwent a grafting procedure for late aneurysm after subclavian flap repair. Late aneurysm after subclavian flap aortoplasty for coarctation is a very rare complication [3, 4]. This is the fifth report of such an aneurysm.

A 14-year-old boy was hospitalized because of a descending thoracic aortic aneurysm. He had undergone subclavian flap aortoplasty for coarctation of the aorta at another hospital when he was 2 years of age. Pediatricians who had been following him recognized enlargement of the thoracic aorta and referred him to our institution. Magnetic resonance imaging and cine magnetic resonance imaging showed a thoracic aortic true aneurysm 5.0 cm in diameter and 12.0 cm in length just distal to the aortic isthmus (Fig 1). A manometric study showed no pressure gradient across the aortic isthmus, that is, the coarctation had been relieved hemodynamically. On the basis of these findings, we diagnosed a late aneurysm of the descending thoracic aorta after subclavian flap aortoplasty for coarctation of the aorta and judged that a graft was indicated.

View larger version (80K): [in this window] [in a new window]   Fig 1. . Preoperative (A) cine magnetic resonance imaging and (B) magnetic resonance imaging. (A) The longitudinal view parallel to the aortic arch shows the shape of the thoracic aortic aneurysm distal to the aortic isthmus. (B) The horizontal view shows a thoracic aortic aneurysm 5.0 cm in diameter.

View larger version (145K): [in this window] [in a new window]   Fig 2. . Postoperative aortogram (digital subtraction aortogram) shows absence of the left subclavian artery, which had been used for the subclavian flap. The graft is patent, although the portion that passes through the lumen of the aneurysm is slightly kinked. The arrows show the proximal and distal anastomotic sites.

	Comment

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McGiffin and colleagues [5] determined the aortic wall stress profile after coarctation repair by synthetic patch aortoplasty using mathematical models. This group concluded that development of true aneurysms after synthetic patch aortoplasty is likely to result from excessive aortic wall stress resulting from patch geometry. Further, these authors reported that aortic wall stress elevations for subclavian flap repairs (low-elasticity modulus patch) are greater than those for synthetic patch repairs with the same patch geometry. This can be explained by the fact that a more elastic patch will allow greater displacement and, hence, more aortic wall thinning. The low incidence of aneurysm formation after subclavian flap repair compared with synthetic patch repair may be explained by the limited size of the subclavian artery patch, which limits the diameter of the repair and hence prevents high aortic wall stress.

Moulton and associates [6] suggested that late aneurysm formation might be expected regardless of whether the patch is synthetic or derived from subclavian artery tissue, as abnormal coarctation tissue and periductal tissue are not excised in either repair technique. Four years later, Martin and colleagues [3] documented the occurrence of late aneurysms after subclavian flap repair in 3 patients, thus lending support to the concept of Moulton and co-workers. None of the 3 patients had undergone any surgical intervention for aneurysm. Berri and colleagues [4] reported the first case of surgically treated late aneurysm after subclavian flap repair for coarctation; ascending aortic-descending aortic extraanatomical bypass grafting was performed using a Dacron graft. Our report is the fifth of late aneurysm formation after subclavian flap repair for coarctation.

Mellgren and associates [7] studied the postoperative development of subclavian flaps in newborn pigs undergoing subclavian flap aortoplasty and found that the wall thickness as well as the strength of the subclavian flap increased by the growth of each of the individual fibroelastic lamellar units in the tunica media. They concluded that the subclavian flap is well suited to function as a part of the aorta in adults. On the other hand, Jonas [8] suggested the following disadvantages of subclavian flap repair: There is histologic evidence that the juxtaductal coarctation shelf is composed of smooth muscle of ductal origin, which subsequently fibroses and may present a risk for late aneurysm development. The fact that this abnormal tissue is not removed is one of the inherent disadvantages of subclavian flap repair, which currently makes resection and end-to-end anastomosis a more attractive alternative.

	Footnotes

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Address reprint requests to Dr Kino, Department of Cardiovascular Surgery, Okayama University Medical School, 2-5-1 Shikata-cho, Okayama 700, Japan.

	References

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1. 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]
2. Bromberg BI, Beekman RH, Rocchini AP, et al. Aortic aneurysm after patch aortoplasty repair of coarctation: a prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989;14:734–41.[Abstract]
3. Martin MM, Beekman RH, Rocchini AP, Crowley DC, Rosenthal A. Aortic aneurysms after subclavian angioplasty repair of coarctation of the aorta. Am J Cardiol 1988;61:951–3.[Medline]
4. Berri G, Welsh P, Capelli H. Aortic aneurysm after subclavian flap angioplasty for coarctation of the aorta. J Thorac Cardiovasc Surg 1993;105:951.[Medline]
5. McGiffin DC, McGiffin PB, Galbraith AJ, Cross RB. Aortic wall stress profile after repair of coarctation of the aorta. Is it related to subsequent true aneurysm formation? J Thorac Cardiovasc Surg 1992;104:924–31.[Abstract]
6. Moulton AL, Brenner JI, Roberts G, et al. Subclavian flap repair of coarctation of the aorta in neonates. Realization of growth potential? J Thorac Cardiovasc Surg 1984;87:220–35.[Abstract]
7. Mellgren G, Friberg LG, Björkerud S. Can we predict the long-term function of the subclavian flap angioplasty? J Thorac Cardiovasc Surg 1992;104:932–7.[Abstract]
8. Jonas RA. Coarctation: do we need to resect ductal tissue? Ann Thorac Surg 1991;52:604–7.[Abstract/Free Full Text]

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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): Shunji Sano Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kino, K. Articles by Kamada, M. Search for Related Content PubMed PubMed Citation Articles by Kino, K. Articles by Kamada, M.