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Ann Thorac Surg 1996;62:782-783
© 1996 The Society of Thoracic Surgeons
Section of Pediatric Cardiovascular Surgery, Rush-Presbyterian-St. Luke's Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612-3833
Doctor Pfammatter and his associates have presented an excellent series of neonates and infants with isolated coarctation and have demonstrated that resection with end-to-end anastomosis undoubtedly is of great value as an operative technique. There is no dispute about this conclusion, and many of our colleagues would agree. I would like to expand their observations as this report nicely demonstrates the need to view coarctation as an entity with a wide spectrum. Pfammatter and associates state that this is a homogeneous group of patients in whom an end-to-end anastamosis had been accomplished; however, this homogeneous group has been divided into three separate groups in regard to surgical therapy. Twenty-seven patients with pure coarctation of the aorta had simple end-to-end anastomosis; 15 patients with a mildly hypoplastic aortic arch underwent an extended end-to-end anastomosis, and finally in 4 patients in whom the ductal tissue extended into the origin of the subclavian artery, an end-to-end anastomosis with implantation of the subclavian artery was performed.
Historically many classifications of coarctation of the aorta have been proposed. However, most of these have been proposed by either cardiologists, anatomists, or pathologists with little attention to the surgical entity at hand. The surgeon, both as a scientist and as an artist, must be attentive to all of these points of view to perform the delicate operations necessary to restore the normal anatomic and hemodynamic milieu. Beginning with Bonnet, who in the Medical Review of Paris in 1908 described coarctation as two types, infantile and adult, and with all of the classifications that followed, surgeons have agreed that coarctation is a spectrum of surgical entities. In approaching the concept of coarctation, surgeons must view it with two considerations in mind. The first is the primary consideration of the anatomic entity. The second is the relationship of the coarctation with coexisting cardiac malformations that change substantially the surgical outcome but, in truth, have no relationship to the type of operation performed for the coarctation itself. In our 1991 article [1] considering the anatomic types of coarctation, my colleagues and I classified coarctation of the aorta into three types. Type I is pure coarctation of the aorta with a discrete shelf and no other involvement of the aorta. Type II would be a coarctation with isthmal hypoplasia. Finally, type III coarctation is with tubular hypoplasia involving the isthmus and the segment between the left carotid and left subclavian arteries, ie, ductal involvement in the proximal left subclavian artery. It is apparent that this classification is germane to the types of operations that Dr Pfammatter and his associates are describing. Although perhaps it is not apparent to Pfammatter and associates, their patient groupings conform to our classification types I, II, and III. In so doing they nicely reconfirm the spectrum of coarctation and support the rationale for three distinct methods of end-to-end anastomotic repair tailored to fit the specific anatomic variation.
A conclusion of this report is that there is no doubt that end-to-end anastomosis is an option of great value. Should then the subclavian flap procedure of Waldhausen be discarded? I believe that, in the judgment of the surgeon, when dealing with a type I discrete coarctation a simple end-to-end anastomosis can be performed; I also believe that an adequate operation can be done with the extended end-to-end anastomosis in type II coarctation with a long narrowed isthmus but no involvement of the subclavian artery. In this instance either the extended end-to-end anastomosis or the subclavian artery flap as used by Waldhausen could be adequately used, and the choice is based on the ability and judgment of the surgeon in the performance of his or her art. However, for a type III coarctation with subclavian involvement, the subclavian flap operation alone will not resolve the problem of ductal tissue within the isthmus and beyond, and therefore the surgical options must include an end-to-end anastomosis after resection of this tissue combined with the use of a subclavian artery. This can be done either as a flap upward or downward or as an implanted segment.
A dimension that may change the course of history is the recent development of balloon angioplasty by our cardiology colleagues. We know that recoarctation can develop after use of any and all surgical techniques. We also know that the clever teamwork of our interventional pediatric cardiology colleagues can address recoarctation of the aorta very successfully with balloon angioplasty. Should then the surgeon's choice of an end-to-end anastomosis over that of the subclavian flap be favored because the latter involves the loss of the subclavian artery function in the child? I believe this factor to be a plausible reason for the surgeon to reconsider the choice of a subclavian flap turndown and to favor the use of end-to-end anastomosis whether it be that of a pure end-to-end, extended end-to-end, or an extended end-to-end with a subclavian tissue implant! Personally I leave open the thought that the surgeon must have multiple options in his or her armamentarium of surgical techniques to face each and every possible variation in the spectrum of coarctation. Again I congratulate Dr Pfammatter and his colleagues on their superb results.
Reference
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