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Ann Thorac Surg 1998;66:1365-1370
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Repair of coarctation with resection and extended end-to-end anastomosis

^a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Chicago, Illinois, USA
^b Division of Cardiology, Children’s Memorial Hospital, Chicago, Illinois, USA
^c Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA
^d Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA

Address reprint requests to Dr Backer, Division of Cardiovascular-Thoracic Surgery-m/c 22, Children’s Memorial Hospital, 2300 Children’s Plaza, Chicago, IL 60614
e-mail: (c-backer{at}nwu.edu)

Presented at the Poster Session of the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Our surgical strategy for infant coarctation changed from subclavian flap aortoplasty to resection with extended end-to-end anastomosis in 1991. The purpose of this review was to evaluate the results of that strategy.

Methods. From 1991 through 1997, 55 infants underwent repair of coarctation of the aorta using resection with extended end-to-end anastomosis. Isolated coarctation of the aorta was present in 26 patients, 20 patients had a ventricular septal defect, and 9 patients had other associated intracardiac lesions. Mean age at surgery was 0.20 ± 0.24 years (median, 21 days). In 34 patients (62%), arch reconstruction was performed through a left thoracotomy. Twenty patients (36%) had median sternotomy with simultaneous repair of coarctation of the aorta and intracardiac repair of associated lesions. One patient had recoarctation repair through a median sternotomy. All coarctation and ductal tissue was resected and the anastomosis was constructed starting opposite the left carotid artery with running polypropylene suture.

Results. There was one early death 26 days after coarctation of the aorta and ventricular septal defect repair in a child on extracorporeal membrane oxygenation for meconium aspiration and 2 late deaths owing to pneumonia and pulmonary hypertension (1) and interventricular hemorrhage (1). There were no instances of paraplegia. Follow-up in survivors ranges from 10 to 76 months (mean, 39.8 ± 17.2 months). Recoarctation has developed in 2 patients, who have had successful balloon dilation 6 and 14 months after the operation. This yields a low recoarctation rate of 3.6%.

Conclusions. Resection with extended end-to-end anastomosis yields a low mortality and particularly a low recoarctation rate and is our procedure of choice for infants with coarctation of the aorta.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Repair of coarctation of the aorta (COA) in neonates using the technique of resection with extended end-to-end anastomosis (REEEA), although first described in the United States [1, 2], appears to have become most widely accepted and applied in Europe at the current time [3–5]. We became interested in using this technique after noting a high incidence of recoarctation in our infant patients undergoing patch aortoplasty [6] and seeing recent reports of higher than previously noted recoarctation rates after subclavian flap aortoplasty [7–9]. The theoretical advantages of REEEA seem clear: resection of all ductal tissue, an anastomosis that addresses tubular hypoplasia of the aortic arch, use of autologous tissue allowing for growth, and preservation of the left subclavian artery. The possible disadvantages of the technique were increased mortality secondary to a more extensive procedure, tension on the suture line leading to bleeding complications, and recoarctation secondary to a circular anastomosis. The purpose of this study was to review our experience with the technique of REEEA with regard to operative mortality, complications related to the technique itself, and the incidence of late recoarctation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
From November 1991 through May 1997, 55 infants with COA underwent surgical repair by REEEA at the Children’s Memorial Hospital, Chicago, Illinois. During this period 4 infants who would have been candidates for REEEA had other operations. One child with a Taussig-Bing anomaly and COA had a Hanley-type repair of the coarctation [10]. One 5-month-old child had a Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ) patch aortoplasty. Two infants had subclavian flap aortoplasty during the transition to REEEA early in this time period. There were 33 boys and 22 girls. Mean age at the time of surgery was 0.2 ± 0.24 years (median age, 21 days). Twenty-six patients (47%) had an isolated coarctation, 20 patients (36%) had an associated ventricular septal defect (VSD), and 9 patients (16%) had an associated intracardiac lesion. These lesions included atrioventricular canal defect (4), atrial septal defect (3), and aortic stenosis (2). The ductus arteriosus was kept patent with prostaglandin E₁ infusion preoperatively in 18 patients (33%). All patients had comprehensive echocardiographic analysis preoperatively. Patients with complex associated cardiac lesions had cardiac catheterization; patients with isolated COA underwent the operation based on echocardiographic findings alone.

Operative techniques
The surgical approach in 34 patients (62%) was through a left posterolateral thoracotomy in the third intercostal space. The surgical approach in 21 patients (38%) was through a median sternotomy and the COA repair was made under circulatory arrest. In these patients simultaneous intracardiac repair of the VSD or associated intracardiac lesion was performed. Arterial pressure monitoring was by means of the right radial artery. In patients operated on through a left thoracotomy the child’s rectal temperature was allowed to drift to 34.5°C. The patients operated on through a median sternotomy were cooled to 18°C for the period of circulatory arrest. The illustrations of the operative technique demonstrate the procedure as performed through a left thoracotomy.

The aortic arch, brachiocephalic vessels, patent ductus arteriosus, and descending thoracic aorta were dissected free. Extensive mobilization of the left subclavian, left carotid, and innominate artery allow the arch to "come down" into the chest to facilitate an anastomosis without tension. Figure 1A demonstrates clamp placement, collateral division, and lines of incision. Although not shown in the illustrations, the recurrent laryngeal nerve was identified and mobilized medially. The proximal clamp occludes the left carotid artery, left subclavian artery, transverse arch, and in patients with severe arch hypoplasia, part of the innominate artery. Excessive tension on this clamp can lead to kinking and occlusion of the ascending aorta. This complication can be prevented by carefully monitoring the right radial artery pressure. Adequate (but not excessive) mobilization of the descending thoracic aorta is obtained by dividing intercostal collaterals. Only as many collaterals as needed are taken. In most cases, we have found it useful to ligate and divide three sets of collaterals as illustrated to provide adequate mobility of the descending thoracic aorta. In some cases as many as five sets of collaterals were divided. The distal clamp is placed well below the anticipated incision line and is used to apply traction, "pulling" the descending thoracic aorta up to the anastomosis site. Heparin is not administered. The ductus arteriosus is ligated proximally and then the clamps are applied. Figure 1B shows the extent of the coarctation resection along with the incision in the undersurface of the aortic arch and the appropriate counterincision in the descending thoracic aorta. The incision in the undersurface of the aortic arch extended proximally to the origin of the left carotid artery. Traction on the upper and lower clamps allows the two aortic ends to come together as shown in Figure 1C. The anastomosis is constructed with running 6-0 or 7-0 polypropylene suture. The initial sutures are placed posteriorly in a "parachute" fashion with most of the posterior sutures placed before pulling the loops tight. When the anastomosis is completed a long, oblique suture line is the final result as shown in Figure 1D.

View larger version (51K): [in this window] [in a new window]   Fig 1. Repair of coarctation of the aorta with resection and extended end-to-end anastomosis through a left thoracotomy approach. (A) Clamp placement, collateral ligation and division, and proposed lines of incision. (B) Ductus arteriosus has been ligated, coarctation specimen is excised, and the undersurface of the aortic arch has been incised up to the left carotid artery, with an appropriate counterincision in the descending thoracic aorta. (C) End-to-end anastomosis is constructed beginning posteriorly with a running polypropylene suture and a "parachute" technique. (D) Completed anastomosis is a long, oblique suture line. (© 1997 by Rachid F. Idriss; printed with permission.)

The technique was modified somewhat in patients undergoing repair through a median sternotomy. The anastomosis was performed under circulatory arrest (18°C) with occlusion of the ascending arterial branches supplying the cerebral vessels (innominate, left carotid, and left subclavian artery) with Rommel tourniquets. Intercostal collaterals were not ligated and divided, but were extensively mobilized. The recurrent laryngeal nerve was identified and preserved. A curved vascular clamp was placed as far distal as possible on the descending thoracic aorta and then used to pull the descending aorta up to the anastomosis. The mean circulatory arrest time was 17.3 ± 4.5 minutes (range, 10 to 23 minutes). After the anastomosis was completed the head vessel snares and distal clamp were released and cardiopulmonary bypass resumed. Intracardiac repair of associated cardiac lesions was then performed. Fourteen patients had VSD closure, 3 had atrioventricular canal repair, 2 had aortic valvotomy, and 1 had sinus venosus atrial septal defect repair. One patient had repair of a recoarctation after prior subclavian flap aortoplasty.

Follow-up
All hospital survivors have been followed up from 10 to 76 months postoperatively (mean, 39.8 ± 17.2 months). All patients have had follow-up echocardiographic analysis including two-dimensional and color Doppler assessment. Arm–leg pressure gradients were also obtained in all patients. Recoarctation was defined as an arm-to-leg gradient of greater than 20 mm Hg [11]. All patients with a question of recoarctation or those with a pulmonary artery band at the initial operation have undergone repeat cardiac catheterization. An example of a typical postoperative angiogram illustrating an excellent postoperative result is shown in Figure 2.

View larger version (175K): [in this window] [in a new window]   Fig 2. Lateral view of left ventriculogram and aortogram 3 months after resection with extended end-to-end anastomosis demonstrating essentially normal aortic arch anatomy with no evidence of a residual coarctation of the aorta. This child also has an atrioventricular canal defect that was repaired later.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
A summary of postoperative mortality and morbidity after REEEA is displayed in Table 1. There was one operative death for an early mortality of 1.8%. The death occurred 26 days after simultaneous repair of COA and VSD in a patient who went to the operating room at 7 days of age while being treated with extracorporeal membrane oxygenation for meconium aspiration. The child died of respiratory failure related to the meconium aspiration. There were two late deaths: 1 child who was repaired through a left thoracotomy, and 1 through a median sternotomy (p = not significant). One child with Down’s syndrome and a complete atrioventricular canal defect died of pneumonia and unrelenting pulmonary hypertension 15 days after atrioventricular canal repair 3 months after COA repair through a left thoracotomy. That child had a cardiac catheterization 5 days before intracardiac repair, which showed systemic levels of pulmonary artery pressure (80/42 mm Hg; mean, 58 mm Hg) and a pulmonary vascular resistance = 9 Wood units; pulmonary vascular resistance dropped to 7 units on O₂ and nitric oxide therapy. The child was ventilator dependent for 4 weeks before intracardiac repair after emergent hospitalization, intubation, and ventilation for pneumonia. The child died of sepsis (white blood cell count, 40,000/µL), pulmonary hypertension, and renal and respiratory failure. A second child died 18 months postoperatively of sudden interventricular hemorrhage. That child had simultaneous VSD closure and COA repair through a median sternotomy. Head ultrasound 3 days postoperatively had demonstrated a right occipital horn interventricular hemorrhage. This same child had recoarctation develop and underwent successful balloon dilation of the arch 14 months postoperatively.

Recoarctation
Two patients (3.6%) had a recoarctation identified postoperatively. Both were noted within several months of the initial procedure and both have had successful balloon dilation by our interventional cardiologists, at 6 and 14 months postoperatively. Repair was performed in 1 patient through a left thoracotomy and in 1 through a median sternotomy (not significant).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Advances in preoperative, intraoperative, and postoperative management have improved to the point where the mortality rate for all types of neonatal coarctation repair has become quite low. Most patients are now taken to the operating room in hemodynamically stable condition thanks to ductal patency from prostaglandin E₁ infusion. The remaining surgical challenge is the prevention of residual or recurrent coarctation. The technique of REEEA addresses many of the anatomic features that can cause recoarctation: resection of all ductal tissue, an anastomosis that relieves tubular hypoplasia of the aortic arch, and use of autologous tissue allowing for growth. Our review of 55 patients operated on with this technique from 1991 through 1997 demonstrates that this technique can be performed with a low operative mortality (1.8%) and a low recoarctation rate (3.6%). Similar results with this procedure have been previously reported by several different groups from Europe [3–5, 12–14]. The results of several other surgeons with the technique of REEEA are shown in Table 2. There seems to be little doubt that the technique of REEEA can be accomplished with both a low mortality and the lowest reported recoarctation rate for neonates.

There are several technical modifications of the technique of REEEA that may be useful for patients with complex transverse arch anatomy. Elliott [23] reported modifying the technique using a partial occlusion clamp also on part of the innominate artery—the "radically extended end-to-end anastomosis." In the experience from Great Ormond Street this technique was associated with the best actuarial freedom from recoarctation [3]. The operation can be performed either through a left thoracotomy or with a median sternotomy for simultaneous intracardiac repair of VSD or complex cardiac lesions [24]. In fact, a recent series demonstrated a better outcome with one-stage repair of neonatal coarctation and associated complex heart defects (with indications for two-ventricle repair) by means of an anterior approach than a two-stage repair [4]. In our series, although not reaching statistical significance, there was a trend toward more recurrent laryngeal nerve injuries and postoperative seizures with the median sternotomy approach. This is mitigated by the fact that these were infants with more complex lesions. Zannini and associates [14] described a modification using a median sternotomy approach and ligating the isthmus. The coarctation is then resected and repaired by anastomosing the transected descending thoracic aorta to the side of the ascending aorta. Van Son and colleagues [5] recommend that for the infant with a "bovine" innominate artery (left common carotid originates at the base of the innominate artery), repair be preferentially performed through a median sternotomy with circulatory arrest with an end-to-side anastomosis of the descending aorta to the ascending aorta.

A possible criticism of our review is the relatively short follow-up (mean, 39 months) compared with some series. Mitigating against this is the fact that most neonatal recurrences are noted in the first year after the procedure. In the review by Sanchez and associates [21], the median postoperative presentation of recoarctation was 5 months. In the review by Zehr and coworkers [22] the mean time to diagnosis of recoarctation was 5 months in the current era. A frequent criticism of this technique is the running suture line for the anastomosis, increasing the potential for recoarctation. We believe this argument is best answered by the now documented low recoarctation rate and the evidence from many more patients having an arterial switch operation with running polypropylene suture [25]. These patients in several large series have a very low incidence of suture line stenosis, despite running suture technique in a small baby [26]. If recoarctation occurs, we believe balloon dilation is the indicated initial therapy of choice, and this was successful in the 2 patients in our series who had recoarctation. Other institutions have reported good results with balloon angioplasty of recoarctation [27].

Repair of COA in infancy with REEEA can be accomplished with both a low mortality and a low recoarctation rate. The repair can be accomplished either through a left thoracotomy or with a median sternotomy using circulatory arrest. Advantages of this technique include resection of all ductal tissue, an anastomosis that corrects immediately an associated hypoplastic transverse arch, preservation of the left subclavian artery and normal vascular anatomy, and use of all autologous tissue to provide growth potential. This operation has replaced the subclavian flap repair as our procedure of choice for infants with COA.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Dr Edward Chen for the statistical analyses.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) 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): Carl L. Backer Constantine Mavroudis Elias A. Zias Zahid Amin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Backer, C. L. Articles by Weigel, T. J. Search for Related Content PubMed PubMed Citation Articles by Backer, C. L. Articles by Weigel, T. J.