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Ann Thorac Surg 1999;68:1392-1394
© 1999 The Society of Thoracic Surgeons

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Case Reports

Aneurysm after subclavian flap angioplasty repair of coarctation of the aorta

^a Division of Thoracic and Cardiovascular Surgery, The Montreal General Hospital, McGill University, Montreal, Quebec, Canada

Address reprint requests to Dr Tchervenkov, The Montreal General Hospital, Rm L9-513, 1650 Cedar Ave, Montreal, PQ, Canada H3G 1A4

	Abstract

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We report a case of aortic aneurysm at the site of subclavian flap angioplasty repair for coarctation of the aorta. The dilatation involved the lateral wall of the proximal descending aorta that had been constructed by the flap. Five other similar cases have been reported in the literature. Diligent long-term follow-up is needed after surgical repair of coarctation of the aorta to detect late complications such as restenosis or aneurysm formation.

	Introduction

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Coarctation of the aorta (CoA), occurring either alone or in association with other cardiac anomalies, constitutes 3% to 5% of all congenital cardiac malformation. Surgical approaches to CoA repair include coarctectomy and end-to-end anastomosis, prosthetic patch aortoplasty, prosthetic tube graft interposition, resection of coarctation shelf together with subclavian flap angioplasty (SFA), or a combination of coarctectomy and SFA. The rate of restenosis appears to be higher after end-to-end anastomosis than that reported after subclavian flap angioplasty on long-term follow-up, probably related to a lack of growth at the circumferential suture line [1]. On the other hand, a high incidence of aneurysm formation has been reported in patients who had prosthetic patch aortoplasty [2]. Subclavian flap for CoA repair described by Waldhausen and Nahrwold [3] has initially been thought to be relatively free of these surgical complications. Recently, we managed a descending thoracic aneurysm at the site of the SFA in a 19-year-old man who had undergone a flap angioplasty for juxtaductal CoA repair at the age of 7 years. Long-term results and complications of different surgical treatments of CoA, particularly SFA, will be briefly reviewed from the literature.

A 19-year-old man was incidentally diagnosed with CoA at the age of 2 years by his physician on a routine physical examination. He underwent a standard subclavian flap angioplasty repair at the age of 7 years. There was no evidence of residual stenosis on regular physical and echocardiographic examinations. In 1994, a routine chest roentgenogram revealed an aortic aneurysm at the level of the aortic knob. Transesophageal echocardiography demonstrated a 7-cm aortic aneurysm at the level of the subclavian flap angioplasty. Subsequently, the patient underwent a magnetic resonance imaging that delineated the 7-cm by 8-cm proximal descending thoracic aortic aneurysm. The aortic arch and the distal descending thoracic aorta were of normal size. The aortic aneurysm was repaired by a left posterolateral thoracotomy through the fifth intercostal space. The fusiform aneurysm was identified extending from a point 1 cm distal to the origin of the left carotid artery for 7 cm of the proximal descending aorta. It was located at the site of the previous coarctation repair, involving the lateral wall of the aorta where the subclavian flap was used. Attenuated and fragmented fine Prolene suture material could be found embedded in the aortic wall. There was minimal adhesion between the aneurysm and the surrounding lung tissue. The aneurysm was resected and the aorta was reconstructed with a No. 20 Hemashield (Meadox Medical Inc, Oakland, NJ) interposition tube graft. The patient recovered uneventfully. Subsequent follow-up with magnetic resonance imaging revealed a normal reconstructed thoracic aorta.

	Comment

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Subclavian flap angioplasty was popularized in the mid-1960s as an alternative to resection and end-to-end anastomosis for CoA repair in an attempt to lower the recoarctation rate associated with the earlier experience with that technique. Larger clinical experience and longer follow-up have, however, indicated that SFA is also associated with a significant incidence of restenosis [1].

Aneurysm formation represents another rare but life-threatening late complication after CoA repair. It is particularly prevalent in patients who had a synthetic patch aortoplasty. In a recent review of the results of CoA repair involving 891 patients, aortic aneurysm developing at the site of repair was noted in 48 patients (5.4%), 90% (43 patients) of which had had synthetic patch aortoplasty [2]. The remaining 5 patients were confined to patients having coarctectomy and end-to-end anastomosis or prosthetic graft interposition. The incidence of aneurysmal formation after synthetic (Dacron) patch aortoplasty increased with the duration of follow-up: 6 patients were detected within 5 years after CoA repair, 32 patients (66.7%) were documented during 6- to 16-year observation periods. In another series, five aneurysms were detected in 38 patients (between 6 and 18 years postoperatively) in whom a Dacron patch had been used for primary CoA repair or to revise an earlier repair [4]. These aneurysms typically occurred in the aortic wall opposite the synthetic patch. These reports identified the serious complications of aneurysm formation associated with synthetic patch angioplasty and suggested to abandon this technique and called for a careful lifelong follow-up of patients who had this type of CoA repair.

Martin and colleagues [5] reported in 1988 aortic aneurysm in 3 patients at the site of previous CoA repair by SFA 2 to 3 years after operation. Two other case reports [6, 7] published within the past 4 years also documented true aneurysm formation at the site of CoA repair 5 to 12 years after SFA. The exact location of the aneurysm in relation to the flap and the native aortic wall were not mentioned in these reports. We noted a true aneurysmal dilatation involving the lateral aortic wall precisely at the site of the subclavian artery flap and not in the native aortic wall where the coarct shelf would have been.

Including our own patient, to date, there have only been 6 patients with aortic aneurysmal formation associated with SFA reported in the literature. Considering the popularity of this procedure in the past and the paucity of reported cases of aneurysm at the site of previous CoA SFA repair, this remains an uncommon complication of this procedure. It is, however, prudent to recommend that patients with SFA repair for CoA should be followed for life so that late aneurysm can be detected and managed accordingly.

	References

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1. Dietl C.A., Torres A.R., Favaloro R.G., et al. Risk of recoarctation in neonates and infants after repair with patch aortoplasty, subclavian flap, and the combined resection-flap procedure. J Thorac Cardiovasc Surg 1992;103:724-732.[Abstract]
2. Knyshov G.V., Sitar L.L., Glagola M.D., Atamanyuk M.Y. Aortic aneurysms at the site of the repair of coarctation of the aorta. Ann Thorac Surg 1996;61:935-939.[Abstract/Free Full Text]
3. Waldhausen JA, Nahrwold DL. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:523–3.
4. Clarkson P.M., Brandt P.W.T., Barratt-Boyes B.G., et al. Prosthetic repair of coarctation of the aorta with particular reference to Dacron onlay patch grafts and late aneurysm formation. Am J Cardiol 1985;56:342-346.[Medline]
5. Martin M.M., Beekman R.H., Rocchini A.P., et al. Aortic aneurysms after subclavian angioplasty repair of coarctation of the aorta. Am J Cardiol 1988;61:951-953.[Medline]
6. Berri G., Welsh P., Capelli H. Aortic aneurysm after subclavian arterial flap angioplasty for coarctation of the aorta. J Thorac Cardiovasc Surg 1993;105:951.[Medline]
7. Kino K., Sano S., Sugawara E., Kohmoto T., Kamada M. Late aneurysm after subclavian flap aortoplasty for coarctation of the aorta. Ann Thorac Surg 1996;61:1262-1264.[Abstract/Free Full Text]

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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): Dao M. Nguyen John Tsang Christo I. Tchervenkov Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nguyen, D. M. Articles by Tchervenkov, C. I. Search for Related Content PubMed PubMed Citation Articles by Nguyen, D. M. Articles by Tchervenkov, C. I.