Ann Thorac Surg 1998;66:588-589
© 1998 The Society of Thoracic Surgeons
How To Do IT
Modified subclavian flap aortoplasty for coarctation repair in patients less than three months of age
Miki Asano, MDa,
Akira Mishima, MDa,
Shigeki Yamamoto, MDa,
Takayuki Saito, MDa,
Tadao Manabe, MDa
a Division of Cardiovascular Surgery, Nagoya City University Medical School, Nagoya, Japan
Accepted for publication April 25, 1998.
Address reprint requests to Dr Asano, Division of Cardiovascular Surgery, Nagoya City University Medical School, 1 Kawasumi, Mizuho-ku, Nagoya 467, Japan
e-mail: (asano{at}med.nagoya-cu.ac.jp)
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Abstract
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Subclavian flap aortoplasty is one of the best procedures for coarctation repair, but recoarctation still remains a problem in neonates and infants. We employed subclavian flap aortoplasty with resection of the whole layer of aortic ductal tissue in 9 patients less than 3 months of age with coarctation of the aorta and obtained satisfactory results.
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Introduction
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The surgical management of coarctation of the aorta has been improved because of the development of both preoperative management and surgical techniques. Although we think coarctation repair should be individualized for each case to optimize the anatomy, subclavian flap aortoplasty (SFA) [1] is still considered to be the operation of choice in neonates and infants with symptomatic coarctation of the aorta. Recoarctation after use of SFA in neonates and infants remains a problem [2, 3]. Therefore, modified SFA, a procedure of SFA combined with partial excision of the aortic ductal tissue, has been our basic tactic for preventing recoarctation after 1994. We have reviewed our experiences in coarctation repair with modified SFA in patients less than 3 months of age.
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Technique
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Between October 1988 and September 1997, 33 infants less than 3 months of age underwent coarctation repair at Nagoya City University Hospital. All cases except simple coarctation of the aorta were scheduled for staged operation. Modified SFA was performed in 9 patients. The remaining procedures consisted of SFA (17 patients), coarctectomy and end-to-end anastomosis (4 patients), and extended aortic arch anastomosis (3 patients). After 1994, we have used modified SFA in patients with an anatomy suitable for the SFA procedure. End-to-end anastomosis was employed in patients who had an aberrant subclavian artery or a very small subclavian artery. We treated patients with aortic arch hypoplasia by extended aortic arch anastomosis.
We used modified SFA for 8 boys and 1 girl. Age at coarctation repair ranged from 10 to 88 days (mean; 43 days; 4 neonates and 5 infants) and the weight ranged from 2,900 to 5,000 g (mean, 3,777 g). There were 2 cases of isolated coarctation, 4 cases with associated ventricular septal defect, and 3 cases with associated complex intracardian anomaly, such as transposition of the great arteries in 2 and Ebstein’s disease in 1. The diagnosis was made with cardiac catheterization and echocardiography in cases with complex anomalies; in the remainder the diagnosis was made clinically and confirmed with echocardiography and aortography with injection from the right radial artery. All 9 survivors at coarctation repair were followed up from 14 to 42 months (mean, 32 months).
By definition, any postoperative stenosis in the repair area giving a resting peak pressure gradient of greater than 20 mm Hg assessed by arm/leg blood pressure was considered as recoarctation after discharge from the hospital. Aortic arch hypoplasia was defined as a ratio of the proximal transverse arch, between the brachiocephalic and left common carotid artery, to the descending aorta of less than 0.5.
The modified SFA was performed as follows. Through a left posterolateral thoracotomy through the fourth intercostal space with an extrapleural approach, the left subclavian artery was mobilized as distally as possible and its branches were ligated and divided. After double ligation of the ductus arteriosus and systemic heparinization (100 IU/kg), a ligature was placed distally on the subclavian artery and vascular clamps were applied across the transverse aortic arch between the left carotid and subclavian arteries and the descending aorta beyond the coarctation site (Fig 1A). The aortic incision was made from 1 cm beyond the coarctation site through the isthmus and along the lateral border of the subclavian artery, which was transected proximal to the ligature (Fig 1B). The whole layer of the circumferential juxtaductal coarctation shelf was resected on all sides up to the normal aortic tissue except for the part with ductal ligations. All but a few millimeters was resutured using knotted, 7-0 nonabsorbable monofilament thread to effectively enlarge the flap. Resuturing at the inmost part of the resection should be sufficiently wide to include any possibly remaining ductal tissue to avoid bleeding and keep the suture line from bending inward (Fig 1C). The distal end of the untrimmed subclavian flap and the lower part of the aortotomy were approximated with a 7-0 anchoring suture. The suture was pulled down to position the flap so as to fit within the margins of the aortotomy (Fig 1D). Two longitudinal continuous running sutures with 7-0 nonabsorbable monofilament threads were started from both proximal ends and finished at the distal end of the flap (Fig 1E).
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Fig 1. (A) Ligation of ductus arteriosus and the left subclavian artery. A straight vascular occlusion clamp is placed at the distal transverse arch and an angled cross-clamp at the descending aorta approximately 1.5 cm below the coarctation site. The dotted line denotes margins of the left subclavian artery resection and arteriotomy incision. (B) Aortic incision from 1 cm beyond the circumferential juxtaductal coarctation shelf. (C) Resection of the ductal tissue on all sides except the part with ligation of the ductus arteriosus. Suturing is relatively wide on both sides of the inmost part of the resection so as not to leave any ductal tissue. The interrupted sutures are completed except for a few millimeters. (D) An anchoring suture for pulling down to fit the flap within the aortotomy. Two longitudinal continuous running sutures are made, starting from both proximal ends, avoiding interrupted suture lines and finishing at the distal end. (E) Completed repair of aortic coarctation by modified subclavian flap aortoplasty.
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Comment
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The advantages of SFA are as follows: the time of operation is shortened for technical reasons and hence the operation can be performed even in critically ill neonates, who have the potential of long-term growth of both the periductal aorta and the pedunculated vascular flap [2, 3]. Meanwhile, recoarctation consistently occurs in infants in whom SFA has been used despite the lower rate of recoarctation after SFA than after other types of repair [4]. Recoarctation is multifactorial, but early occurrence is attributed to the remaining circumferential ductal tissue extending from the ductus arteriosus in SFA [5]. We have experienced 5 recoarctation cases out of 17 cases in which SFA was used (29%). Recoarctation occurred 2 and 5 months after coarctation repair, and percutaneous balloon angioplasty was performed successfully.
In modified SFA, there were no deaths related to coarctation repair, but 1 patient (11%) showed recoarctation 4 months after the initial operation at 2 months of age. The infant showed no residual pressure gradient after coarctation repair. Inadequate removal of ductal tissue seemed to be the reason, and care should have been taken to excise the tissue during resection. The aortic cross-clamp time of modified SFA was 8 minutes longer on average than that for SFA, but it will be improved by continuous sutures for anastomosis of the resected side of the coarctation segment.
A technique similar to modified SFA as described in this article, coarctectomy and end-to-end anastomosis enlarged with subclavian artery flap, has been reported [6]. The major difference is that the ductal tissue is partially excised but the ligated ductus remains in continuity with the aorta in modified SFA. Preserving the continuity is the key to facilitating the procedure safely in modified SFA.
Although the follow-up period and number of cases were limited, the present study indicates that modified SFA is a simple procedure that promises good long-term results. Also, the majority of the recoarctation occurs within the first year of life [3, 7].
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References
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- Waldhausen J.A., Nahrwold D.J. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532-538.[Medline]
- Sanchez G.R., Balsara R.K., Dunn J.M., et al. Recurrent obstruction after subclavian flap repair of coarctation of aorta in infants. Can it be predicted or prevented?. J Thorac Cardiovasc Surg 1986;91:738-746.[Abstract]
- Ziemer G., Jonas R.A., Rerry S.B., et al. Surgery for coarctation of the aorta in the neonate. Circulation 1986;74(Suppl 1):25-31.
- Zehr K.J., Gillinov A.M., Redmond J.M., et al. Repair of coarctation of the aorta in neonates and infants: a thirty-year experience. Ann Thorac Surg 1995;59:33-41.[Abstract/Free Full Text]
- Jonas R.A. Coarctation: do we need to resect ductal tissue?. Ann Thorac Surg 1991;52:604-607.[Abstract]
- Dietl C.A., Torres A.R. Coarctation of the aorta: anatomic enlargement with subclavian artery: two new surgical options. Ann Thorac Surg 1987;43:224-225.[Abstract]
- Merrill W.H., Hoff S.J., Stewart J.R., 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]
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Abstract
Introduction
