Ann Thorac Surg 2005;79:1795-1796
© 2005 The Society of Thoracic Surgeons
How to do it
Left Pulmonary Arterioplasty—Extended End-to-End Anastomosis
Yoshihiro Oshima, MDa,*,
Doi Yoshiro, MDa,
Chikashi Shimazu, MDa,
Takuro Misaki, MDa
a Department of Surgery (I), Toyama Medical and Pharmaceutical University, Toyama, Japan
Accepted for publication December 22, 2003.
* Address reprint requests to Dr Oshima, Department of Surgery (I), Toyama Medical and Pharmaceutical University, 2630 Sugitani, Toyama, 930-0194 Japan
oshima{at}ms.toyama-mpu.ac.jp
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Abstract
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Surgical arterioplasty for left pulmonary branch stenosis often produces unsatisfactory results. We report a new operative approach involving a modification of end-to end anastomosis, providing a widely patent and nonredundant anastomosis.
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Introduction
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Surgical arterioplasty for left pulmonary branch stenosis has often produced unsatisfactory results. We describe a new operative approach that involves a modification of the end-to end anastomosis and provides a widely patent and nonredundant anastomosis.
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Technique
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The operation is performed through a median sternotomy. In cases that require an additional aortoplumonary shunt, a standard left posterolateral thoracotomy is performed. The left pulmonary artery (PA) and pulmonary trunk are completely dissected and mobilized to allow anastomosis without tension. The distal portion of the left PA is mobilized, including the left upper and middle lobe branches. The right PA is also dissected free. If necessary, a vascular occlusive clamp is placed on the distal portion of the left PA across the origin of the left upper lobe branch. Abnormal periductal tissue is then excised. The distal left PA incision is made into the wide poststenotic segment on the superior aspect of the left main PA, and it is extended to approximately the same level as the upper lobe branch. The proximal incision is made on the inferior aspect of the pulmonary trunk as proximally as possible to match the orientation of the distal incision. The anastomosis is completed with a running suture of 7-0 polypropylene (Fig 1).
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Fig 1. The left pulmonary artery (PA) and pulmonary trunk are completely dissected and mobilized. Abnormal periductal tissue is then excised. The distal left PA incision is made into the wide poststenotic segment on the superior aspect of the left main PA, and it is extended to approximately the same level as the upper lobe branch. The proximal incision is made on the inferior aspect of the pulmonary trunk as proximally as possible to match the orientation of the distal incision. The anastomosis is completed with a running suture of 7-0 polypropylene.
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From March 2002 to July 2003, 3 patients underwent the left PA reconstruction using this technique. The first case was a 1-year-old girl referred to our hospital owing to severe cyanosis. She had had a right classic Blalock-Taussig shunt for pulmonary atresia, atrioventricular discordance, ventriclular septal defect, and hypoplastic left ventricle. Preoperative echocardiography showed a hypoplastic left PA. Cardiac catheterization was performed, and a PA arteriogram revealed severe left pulmonary branch stenosis (Fig 2A). Measurements taken from the pulmonary arteriogram showed the stenotic segment of the left PA to be approximately 3.5 mm in diameter. In this case, relief of the left pulmonary stenosis and modified Blalock-Taussig shunt was carried out through a standard left posterolateral thoracotomy. The other 2 patients were an 11-month-old boy and a 1-year-old girl, both with tetralogy of Fallot and left PA branch stenosis (Fig 3A). We performed on both patients a total correction of tetralogy of Fallot and left pulmonary arterioplasty using cardiopulmonary bypass. The procedure was well tolerated, and there were no deaths in the immediate perioperative or midterm postoperative periods. Postoperative echocardiographic Doppler evaluation was performed on all 3 patients and showed no apparent diminished flow, as the measurement of blood pressure, at the left PA branch. Perfusion lung scans in 2 patients with tetralogy of Fallot 5 and 18 months, respectively, after surgery showed normal findings. Postoperative cardiac catheterization was performed on 2 patients 16 and 19 months, respectively, after surgery. These patients had no residual gradients at the left PA branch. Postoperative angiograms demonstrated complete relief of the stenosis with normal left PA dimensions and anatomical structure (Figs 2B and 3B).
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Fig 2. Pulmonary arteriogram (frontal view) of the first case with pulmonary atresia before (A) and after (B) surgical relief of the severe left pulmonary stenosis.
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Fig 3. A selected lateral frame from a pulmonary arteriogram of an 11-month-old boy with tetralogy of Fallot before (A) and after (B) surgery.
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Comment
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The relationship between stenosis of the left PA and the ductus arteriosus is well known and is referred to as juxtaductal pulmonary artery coarctation [1]. Ductal tissue in a PA and PA stenosis frequently appear together in tetralogy of Fallot with pulmonary atresia. It is therefore likely that branch PA stenosis is related to the ductus arteriosus insertion site, which should thus be an important technical consideration when performing surgery. The operative technique usually includes angioplasty of the ductus insertion site at the time of complete repair. In the past, a transannular patch was extended distally past the ductus insertion site for patients with tetralogy of Fallot, but residual stenosis often occurred because of the posterior deviation of the left PA. A separate patch technique is easier to tailor to the angulation of the left PA, with a pericardial patch used for angioplasty and the proximal transannular patch [2]. Although pericardial patch enlargement of the left PA coarctation is easily accomplished, recurrent stenosis often develops due to the redundancy of the patch. If the stenosis is localized, it is preferable to treat the stenosis by resection and reimplantation of the left PA into the pulmonary trunk. A recently developed anastomotic technique has been more favorable, although recurrence of restenosis is still problematic.
We report a new operative technique involving a modification of end-to-end anastomosis, providing a widely patent and nonredundant anastomosis. This procedure is indicated for both types of left PA origin: tubular hypoplasia and that with a localized ridge. However, extensive mobilization of the pulmonary arteries is necessary for direct anastomosis. Therefore, this technique is applicable in the initial procedure.
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References
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- Elzenga NJ, von Suylen RJ, Frohn-Mulder I, et al. Juxtaductal pulmonary artery coarctation. An underestimated cause of branch pulmonary artery stenosis in patients with pulmonary atresia or stenosis and a ventricular septal defect. J Thorac Cardiovasc Surg. 1990;100:416–424[Abstract]
- Hennein HA, Mosca RS, Urcelay G, et al. Intermediate results after complete repair of tetralogy of Fallot in neonates. J Thorac Cardiovasc Surg. 1995;109:332–344[Abstract/Free Full Text]
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Abstract
Introduction
