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Ann Thorac Surg 2001;72:294-295
© 2001 The Society of Thoracic Surgeons

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How to do it

Aortopexy reduces anastomosis stress after repair of coarctation

Accepted for publication January 13, 2001.

Address reprint requests to Dr Vazquez-Jimenez, Department of Thoracic and Cardiovascular Surgery, University Hospital, Pauwelsstrasse 30, D-52057 Aachen, Germany
e-mail: jvazquez-jimenez{at}post.klinikum.rwth-aachen.de

	Abstract

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Restenosis after repair of coarctation with hypoplastic distal aortic arch is an important complication. Complete removal of ductal tissue, resection of isthmus area, and side-to-side arterioplasty of the distal aortic arch leads to a wide distance between the aortic arch and descending aorta; therefore, the anastomosis may remain under tension, increasing risk of restenosis. To reduce the tension, aortopexy of the descending aorta was used. The operative technique and the results in 16 neonates and infants are presented.

	Introduction

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Restenosis after repair of complex aortic coarctation arch in neonates and infants is an important complication [1]. Incomplete removal of ductal tissue and tension on the suture lines may increase the risk of restenosis at the anastomosis area. Furthermore, inadequate treatment of the tubular hypoplasia of the distal transverse aortic arch will maintain the gradient between the ascending and descending aorta [2]. Since the ductal tissue may be present not only at the insertion site of the ductus arteriosus but also proximally at the isthmus and distally at the descending aorta, complete resection of the coarctation, isthmus, and proximal border of the descending aorta has to be performed to ensure complete removal of the ductal tissue [2, 3]. This maneuver will increase the distance between the aortic arch and the descending aorta and, therefore, the tension on the later end-to-end anastomosis.

Hypoplasia of the distal transverse aortic arch can be treated effectively by side-to-side left carotid-subclavian arterioplasty as described by Amato and colleagues [4]. However, with this technique the enlarged aortic arch is displaced cranially and to the right, additionally increasing the distance between the aortic arch and the descending aorta.

Even after extensive dissection and mobilization, the end-to-end anastomosis between the enlarged aortic arch and the descending aorta remains under tension, thus increasing the risk of restenosis. Since 1998, aortopexy of the descending aorta has been performed in 16 neonates and infants to reduce the tension on the suture lines.

	Techniques

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Operative technique
Esophageal temperature was lowered to 29°C by external body cooling. Arterial blood pressure was monitored through a right radial or brachial arterial line. A full left thoracotomy through the third intercostal space was performed in all patients with complex coarctation. In patients with simple coarctation a standard left posterolateral thoracotomy was performed. After incision of the mediastinal pleura, careful dissection and extensive mobilization of the proximal aortic arch to the basis of the innominate artery, to the left carotid and subclavian artery and its proximal branches, the ductus, the coarctation area, and the descending aorta under the fourth intercostal arteries were done. Preoperative gradient was measured by inserting a needle in the descending aorta and comparing the pressure with the right arm arterial line.

After heparinization with 1 mg heparin/kg body weight, different surgical strategies were used with regard to the surgical anatomy.

In all patients with simple coarctation a wide end-to-end anastomosis between the aortic arch and the proximal descending aorta was performed using a 6-0 polydioxanon (PDS; Ethicon, Inc, Somerville, NJ) running suture.

In patients with complex coarctation the aortic cross-clamp was placed directly distal to the basis of the innominate artery. The left carotid and subclavian artery were temporarily snared. The coarctation area was temporarily occluded with a vascular clamp maintaining the ductus patent. If the distance between the left carotid artery and the left subclavian artery was short and the diameters of both vessels were not too small, an incision was made extending from the medial proximal portion of the left subclavian to the lateral proximal portion of the carotid artery. A side-to-side anastomosis, as described by Amato and coworkers [4], with a continuous 7-0 polydioxanon suture was performed. The clamps were removed and the anastomosis was controlled. The ductus was transsected between two 5-0 polypropylene sutures (Prolene; Ethicon, Inc, Somerville, NJ). An angled aortic cross-clamp was placed again directly distal to the basis of the innominate artery occluding also the left carotid and subclavian arteries; a second clamp was placed on the descending aorta at the level of the third intercostal arteries. After resection of the coarctation area and careful search for ductus tissue, the incision at the basis of the subclavian artery was prolonged proximally to the basis of the innominate artery and an end-to-end anastomosis of the oblique cut descending aorta to the aortic arch using 7-0 PDS suture was performed [5]. The clamps were removed and hemostasis was controlled.

If the anatomical situation was not suitable for Amato’s technique the incision at the basis of the subclavian artery was prolonged proximally to the basis of the innominate artery and an end-to-end anastomosis of the oblique cut descending aorta to the aortic arch using 7-0 PDS suture was performed.

Independent of coarctation anatomy and surgical repair, aortopexy was used to reduce anastomosis stress.

Aortopexy technique
A 6-0 PDS suture was first placed at the adventitia of the descending aorta 2 mm over the origin of the second left intercostal artery and then 1 cm craniolateral at the thoracic wall into the parietal pleura. By tightening the suture the descending aorta is pulled cranially. This procedure is repeated at the level of the third and between the third and fourth left intercostal arteries (Fig 1). By this maneuver the left margin of the descending aorta is pulled upward and closer to the aortic arch, thus minimizing the tension of the anastomosis. Pressures across the anastomosis before and after aortopexy revealed that gradients of 4 to 6 mm Hg disappeared after this simple technique.

View larger version (24K): [in this window] [in a new window]   Fig 1. After the repair of complex coarctation (A) the descending aorta is pulled cranially by three interrupted 6-0 absorbable sutures (B), decreasing the tension of the anastomosis (C).

	Comment

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All patients survived the operation. No negative effects (eg, mediastinal bleeding or aortic distortion) caused by aortopexy were observed. One patient with multiple cardiovascular abnormalities (Shone complex) died 29 days after the operation because of acute respiratory insufficiency; this patient had no stenosis of the arch or isthmus area. In the remaining patients short-term follow-up (mean 7.8 months, range 0.5 to 20 months) 9 of 11 (82%) patients with former complex coarctation did not reveal any systolic pressure gradients (manometric measured) between upper and lower limbs; in 2 patients the systolic gradients were 13 and 16 mm Hg, respectively. In these 9 patients the flow over the former coarctation area ranged between 1.9 and 2.9 m/s. In the 2 patients with measured systolic gradients the flow was 2.7 and 2.9 m/s, respectively. In the patients with simple coarctation 2 of 5 (40%) patients showed no systolic pressure difference (flow 2.6 and 2.7 m/s); in the remaining 3 patients the systolic gradients were 3, 6, and 16 mm Hg (flow 2.2, 2.1, and 1.9 m/s).

In conclusion we think that this technique can help to reduce anastomosis stress after repair of coarctation, but long-term follow-up is necessary to prove its efficacy.

	References

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1. Van Heurn L.W.E., Wong C.M., Spigelhalter D.J., et al. Surgical treatment of aortic coarctation in infants younger than three months: 1985 to 1990. J Thorac Cardiovasc Surg 1994;107:74-86.[Abstract/Free Full Text]
2. Conte S., Lacour-Gayet F., Serraf A., et al. Surgical management of neonatal coarctation. J Thorac Cardiovasc Surg 1995;109:663-675.[Abstract/Free Full Text]
3. Russell G.A., Berry P.J., Watterson K., Dhasmana J.P., Wisheart J.D. Patterns of ductal tissue in coarctation of the aorta in the first three months of life. J Thorac Cardiovasc Surg 1991;102:596-601.[Abstract]
4. Amato J.J., Rheinlander H.F., Cleveland R.J. A method of enlarging the distal transverse arch in infants with hypoplasia and coarctation of the aorta. Ann Thorac Surg 1977;23:261-263.[Abstract]
5. Lacour-Gayet F., Bruniaux J., Serraf A., et al. Hypoplastic transverse arch and coarctation in neonates. Surgical reconstruction of the aortic arch: a study of sixty-six patients. J Thorac Cardiovasc Surg 1990;100:808-816.[Abstract]

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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): Bruno J. Messmer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vazquez-Jimenez, J. F. Articles by Messmer, B. J. Search for Related Content PubMed PubMed Citation Articles by Vazquez-Jimenez, J. F. Articles by Messmer, B. J. Related Collections Great vessels