Ann Thorac Surg 2006;81:243-248
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Muscle-Sparing Extrapleural Approach for the Repair of Aortic Coarctation
Hitendu Hasmukhlal Dave, MCh
a
,
*
,
Emanuela R. Valsangiacomo Buechel, MD
b
,
René Prêtre, MD
a
a Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Switzerland
b Department of Cardiology, University Children's Hospital Zurich, Switzerland
Accepted for publication June 20, 2005.
* Address correspondence to Dr Dave, Division of Congenital Cardiovascular Surgery, University Children's Hospital (Kinderspital Zurich), Steinwiesstrasse 75, CH-8032, Zurich, Switzerland (Email: hitendu.dave{at}kispi.unizh.ch; hitendu{at}hotmail.com).
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Abstract
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BACKGROUND: This paper describes a muscle-sparing, extrapleural approach to repair aortic coarctation, and evaluates the results with established standards.
METHODS: Forty consecutive patients with aortic coarctation (median age, 8 days; weight, 3.3 kg) were approached with a less invasive technique consisting of a short posterior thoracotomy, with only minimal (24 patients) or no (16 patients) division of thoracic wall muscles and a subperiosteal-extrapleural approach. Extended resection of the coarctation with enlargement of the distal aortic arch was performed in all patients. The median cross-clamp and operative times were 22 and 90 minutes, respectively.
RESULTS: The repair was possible in all patients without needing conversion. There was no intraoperative or postoperative related complication. Two patients died early of low cardiac output as a result of ventricular fibroelastosis and respiratory failure. One patient died late of unrelated cause. The perioperative mean gradients across the neoarch were less than 5 mm Hg in all but 3 patients with proximal (2 patients) or mid arch (1) stenosis. The median ventilation time, intensive care unit stay, and hospital stay in isolated coarctation repairs was 2, 4.5, and 11 days, respectively. One patient had a recurrent stenosis at the site of surgical repair. Two patients underwent successful balloon dilatation, and 2 had surgical enlargement plasty of the proximal aortic arch at the time of intracardiac repair. None of the patients required chronic antihypertensive medication. At 29 months, freedom from reintervention on the isthmus and arch plus isthmus was 97.1% and 89.7%, respectively.
CONCLUSIONS: A muscle-sparing, extrapleural approach for the repair of aortic coarctation is possible and provides results similar to conventional techniques. The approach reduces postoperative morbidity related to division of thoracic wall muscles and handling of the lung, restores a normal intercostal space, and produces superior cosmetic results, while at the same time leading to early and permanent relief of proximal hypertension.
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Introduction
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The surgical treatment of aortic coarctation aims at adequate eradication of the pressure gradient with techniques that allow subsequent harmonious growth. Over the course of years and with experience, aortic isthmus resection and end-to-end anastomosis has become the surgical gold standard. Early and long-term results have been reported to be excellent [1, 2]. Recently, balloon angioplasty of native aortic coarctation has been proposed as an alternative to surgical resection [3–5]. Although balloon dilatation for aortic coarctation in infants has shown a very high rate of restenosis ranging from 8% to 57% [6–8], it is appealing to some cardiologists because of its less invasive characteristics, when compared with standard surgery.
In accordance with a wide-ranging program of minimally invasive surgery for congenital heart defects, we progressively developed an approach for surgical repair of aortic coarctation that minimizes invasiveness by reducing the length of the incision, avoiding division of any thoracic muscles, and by entering the thorax with a subperiosteal and an extrapleural route. During all this experience, priority was not given to the minimally invasive approach, but to the surgical correction, which, in our unit, consisted of an extended resection of the coarctation and an end-to-end anastomosis of the descending aorta to the distal aortic arch, whatever the type of coarctation. This paper describes our less invasive approach, and compares its results with established standards.
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Material and Methods
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All the patients operated on by a single surgeon (R.P.) for aortic coarctation through a left posterior minithoracotomy approach since introduction of our minimally invasive program (July 2002 to November 2004) were reviewed and are included. The demographic and clinical data are summarized in Table 1. The operation was usually performed within 2 days after establishment of the diagnosis regardless of the patient's age. However, 5 patients underwent primarily balloon dilatation. In 3 patients, it was to obtain an access to dilate a concomitant neonatal aortic stenosis. In 2 patients with extreme reduction of left ventricular function, dilatation was performed to allow recovery of ventricular function before surgical resection was undertaken. The coarctation was operated on at 1, 21, and 150 days after dilatation in the aortic valve stenosis group, and at 3 and 75 days in the other group. Nine neonates were receiving prostaglandin therapy. The aortic coarctation was an isolated cardiac defect in 12 patients and was associated with other cardiac or extracardiac anomalies in 28 patients (Table 2).
Technique of Repair
The reduced invasiveness consisted of two modifications compared with the standard techniques:
- 1 Reduction in the length of the incision and preservation of thoracic wall muscles: A 5 to 6 cm, exclusively posterior incision was performed between the posterior border of the scapula and the spine (Fig 1A). The subcutaneous tissue was extensively undermined to allow mobilization of the incision. The latissimus dorsi muscle was disinserted from its attachments to the posterior aponeurosis for 6 to 7 cm (this incision is almost perpendicular to the skin incision; see Fig 1B). Although in the initial part of the experience (n = 18) or when a pulmonary artery banding was simultaneously performed (n = 6) the posterior part of the latissimus dorsi was divided for 2 to 3 cm, it was no longer divided in the later part of our experience (n = 16; Fig 1B). The serratus anterior was left untouched (when necessary, it was only disinserted from the fifth rib to extend the thoracotomy anteriorly especially in older children). A right-angled retractor was inserted underneath these thoracic muscles, and the fifth rib was freed as anteriorly as possible.
- 2 Subperiosteal and extrapleural entrance: The intercostal space was opened by separating the periosteum from the superior border of the fifth rib using a periosteum elevator (Fig 2A). Intercostal muscle fibers were not divided, and their insertion onto the periosteum was left intact. The parietal pleura was identified but not entered. It was gently released, first from the thoracic wall, and then from the descending aorta and the aortic arch. Four 6-0 stay stitches were placed at regular intervals on the extrapleural tissue just medial to the descending aorta or the left subclavian artery (LSA) to retract the left lung. This type of retraction was extremely efficient to get the left lung out of the field without ever handling it with instruments and without producing any compromising compression of the lung vessels (Fig 2B).
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Fig. 1. (A) Artist's depiction of the incision for posterior minithoracotomy, directly overlying the so-called auscultatory gap. This triangle is bound by the trapezius medially, the border of scapula laterally, and the latissimus dorsi inferiorly. (B) Intraoperative demonstration of this triangular space during muscle-sparing approach to the thorax. The skin marker line parallel to and a few centimeters above the skin incision corresponds to the border of the scapula, and the fold of muscle grasped with the forceps represents the latissimus dorsi. Inset picture shows the vertical opening in the muscle-free triangular space.
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Fig. 2. (A) Subperiosteal entry into the thoracic cage. Note the intact intercostal muscles anchored onto the periosteum. (B) Extrapleural approach to the aortic isthmus. Note the intact pleura protecting the lung, and the satisfactory exposure (inset).
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Resection of Coarctation and Plasty of Distal Aortic Arch
The aortic arch and arch vessels were fully dissected and mobilized. The descending aorta was mobilized over a few intercostal spaces (usually down to the seventh). One to two pairs of intercostal arteries were ligated or clipped, and divided. The mobilization of the aorta was sufficient to permit an extended resection and direct anastomosis of the descending aorta underneath the distal aortic arch, without tension. The aortic arch was cross-clamped (using a Cooley clamp) between the truncus brachiocephalicus and the left common carotid artery. This clamp was set on the left common carotid artery as well. A clip was applied with a handheld instrument to temporarily clamp the LSA. The distal cross-clamp (straight vascular clamp) was set on the descending aorta at the level of T4. If an intercostal artery was not included in the clamp, it was temporarily occluded by gently applying a clip. The ductus arteriosus was ligated or sutured and sectioned. The coarctation was resected. The incision was prolonged underneath the aortic arch up to the proximal clamp (the incision usually reached the aorta underneath the left common carotid artery). The descending aorta was fashioned to fit the aortic arch opening, with an incision on the lateral part of the aorta. The anastomosis was performed in a classic way with a running suture of 7-0 or 8-0 polydioxanone (PDS*II; Ethicon–Johnson & Johnson International, St-Stevens-Weluwe, Belgium). Air was removed from the aorta, and the clamps (including the clip on the left subclavian and the intercostal arteries) were removed.
The retracted parietal pleura was allowed to fall on the exposed aorta (Fig 3A). A periosteal analgesia delivery catheter was left free in the extrapleural space for postoperative pain relief. A low-vacuum drain (Mini Redovac B; Braun, Melsungen, Germany) was placed in the space. If air was seen in the pleural space, the tip of the drain was introduced in the pleural space as well. The intercostal space was reconstructed by reapproximating the peeled off periosteum onto the bare rib bed using continuous absorbable sutures (Fig 3A, inset). The latissimus dorsi was reattached onto the thoracolumbar fascia, and the skin was closed in two layers using absorbable sutures (Fig 3B).
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Fig. 3. (A) Intact thoracic muscles after resection of coarctation and anatomic reconstruction of the intercostal space using continuous absorbable suture (inset). (B) Sutured fascia (inset) and posterior minithoracotomy incision. (Top of each figure represents the head end of the patient.)
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Modifications and Additional Procedures
In 2 patients the LSA was used to make a patch enlargement of the distal aortic arch. It was transected high in the chest and used as a reverse flap. In 4 other patients with a particularly long segment between the left common carotid artery and the LSA, the arch was transected at the origin of the LSA to allow a connection of the descending aorta to the aortic arch as medial as possible to augment the hypoplastic arch. The LSA was reimplanted onto the left common carotid artery (2 patients) or onto the enlarged distal arch (4 patients). Similarly, an aberrant right subclavian artery was reinserted on the distal aortic arch. Six patients underwent simultaneous banding of the pulmonary artery. In these patients, at the end of the aortic repair, the pleural space was entered to access the pericardial space. The repair was evaluated with pressure measurements intraoperatively: invasively in the right radial artery and noninvasively on the thigh. Transthoracic echocardiography was performed during hospital stay and during outpatient evaluations (between 3 and 6 months and next at 12 months after discharge). The patients were subsequently evaluated by the peripheral pediatric cardiologist on a regular basis. Follow-up ranged from 1 to 29 months (median, 16.3 months) and was available in all.
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Results
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Resection of the coarctation and anastomosis of the descending aorta on the distal aortic arch was possible in all patients without having to alter the approach. There were no perioperative related complications, except a chylothorax in 1 patient, necessitating surgical chylostasis 12 days after surgery. No patient experienced postoperative spinal cord, renal, or visceral ischemia. There were 3 (2 early and 1 late) deaths, none related to the surgical repair of the aortic coarctation. One patient with a Shone's complex, right diaphragmatic hernia, and lung hypoplasia died on day 2 of respiratory failure. Another patient with severe reduction of left ventricular function, attributable to left ventricular endocardiac fibroelastosis, and moderate to severe aortic regurgitation after balloon dilatation for congenital aortic stenosis died on day 3 as a result of intractable low cardiac output. The late death occurred at 7 months as a result of intestinal necrosis, sepsis, and multiorgan failure. In all 3 patients, the aortic repair had restored a nonobstructive aorta.
The median duration of ventilation in patients with isolated coarctation of aorta was 2 days (2.7 ± 2.3 days), whereas the median duration of intensive care unit stay and hospital stay were 4.5 days (5.3 ± 3 days) and 11 days (13.8 ± 8.4 days), respectively. One patient had a recurrent stenosis at the isthmus location 4.5 months after surgery. The stenosis was successfully dilated by balloon. Three patients showed residual stenosis at the proximal (2 patients) or mid (1 patient) aortic arch. Those with the proximal stenosis underwent surgical patch plasty of the aortic arch at the time of correction of an associated cardiac defect (72 and 82 days after primary repair), and the one with mid-arch stenosis underwent balloon dilatation at 98 days. These patients had no residual stenosis after reintervention.
Although the freedom from reoperation on the aortic isthmus was 100%, the freedom from reoperation on either the arch or the isthmus was 94.6% ± 3.7% (mean ± standard error of mean) at 12 and 29 months (Fig 4A). Similarly, whereas the freedom from any reintervention (transcatheter or surgical) on the operated isthmus was 97.1% ± 2.8%, that on either the arch or the isthmus was 89.7% ± 4.9% at 12 and 29 months (Fig 4B).
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Fig. 4. Kaplan-Meier survival curves depicting freedom from reoperation (A) and freedom from reintervention (B) on the aortic isthmus as well as on the aortic arch or the isthmus.
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Follow-up echocardiography showed no significant gradients across the reconstructed segment. None of the patients were on antihypertensive medication at last follow-up (early 2005).
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Comment
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In contemporary practice, extended resection and direct anastomosis has superseded all other alternative surgical techniques as the treatment of choice for primary correction of native aortic coarctation in childhood [7, 9]. The reason for its popularity is that it provides the best anatomic relief of obstruction, lowest risk of restenosis, and probably the lowest incidence of late aneurysm formation [10, 11].
Beginning in the 1980s, there has been increasing interest in balloon angioplasty, especially for dilatation of restenosis after surgery and for dilatation of native coarctation in adult patient populations [5]. Although the refinements in hardware and technique and the advent of stents (to prevent elastic recoil–restenosis) have improved the initially high incidence of repeat coarctations and incidence of aneurysms, the overall risk-benefit ratio of interventional treatment for native coarctation in infants and young children is unfavorable [6]. Not only is the incidence of restenosis in infants quite high (up to 50%), probably related to constriction of the ductal tissue, the incidence of aneurysm formation (5% to 20%), dissection, rupture, and damage to the vascular access site are not negligible either [4, 7].
Various studies have highlighted the importance of optimum relief of obstruction and proximal hypertension for long-term survival [12–14]. Residual hypertension in the absence of residual stenosis appears to be related to the duration of preangioplasty upper body hypertension causing inadequate resetting of baroreceptors, which never regain normalcy after correction [15]. Incidence of late hypertension in patients repaired in infancy is documented to be significantly lower (4.2%) compared with those operated on later in life (27.1%) [16]. In our experience, with an intent to early surgical repair of aortic coarctation (preferably in the neonatal period), none of our patients suffered from chronic hypertension. The significant shortening of the duration of proximal hypertension by this strategy could have positive prognostic influence.
In spite of inferior results of interventional procedures in children, this approach may appear appealing to the patient owing to its noninvasiveness. We have progressively adopted changes in our surgical techniques that reduce invasiveness of surgical approach, while at the same time harvesting the advantages of early correction. The essential components of reduced invasiveness we used included the following:
- 1 Shorter posterior thoracotomy incision (5 to 6 cm) directly overlying the triangular muscle-free auscultatory gap bound by the border of the scapula, the latissimus dorsi, and the trapezius muscles (Fig 1A).
- 2 Separating the latissimus dorsi muscle from the thoracolumbar aponeurosis without transecting any muscle fibers, thus maintaining early and late normal functional integrity of the important muscles of the upper torso (Fig 1B).
- 3 Subperiosteal thoracic approach avoiding division of intercostal muscle fibers (Fig 2A). The insertion of the intercostal muscles on the periosteum is preserved, and the peeled off strip of periosteum (from the superior rim of the rib) acts like an anchor for the intercostal muscles, thus helping anatomic reconstruction of the intercostal space during closure.
- 4 Extrapleural approach (Fig 2B) to the aortic isthmus makes this procedure virtually a subcutaneous one. The exposure of the aortic isthmus is good, and it resembles the one obtained in a retroperitoneal approach to the abdominal aorta, in which the viscera are held en bloc out of the field in the peritoneum. Use of an extrapleural approach to reach the aortic isthmus, however, is not new [17–19], but appears to be underutilized. As most of the coarctation repairs are performed in infancy when the pleura is free from episodes of pleural inflammation, peeling off the parietal pleura from the bony cage never proves difficult. The intact pleura insulates the lung from the trauma of handling during surgery. It ensures an adhesion-free hemithorax, which is advantageous for subsequent operations. This approach is quick and provides comfortable exposure to the arch and the aorta descendens. We further believe that this approach reduces the formation of adhesions between the lung and the parietal pleura, which can be highly vascular and significant in patients with coexisting intracardiac lesions causing systemic cyanosis.
The absence of significant morbidity and the efficient relief of stenosis compares favorably with the best results of surgical and interventional treatment. Freedom from reoperation on the isthmus of 100% and freedom from balloon reintervention of 97.1% ± 2.8% (Fig 4) at 29 months (median follow-up, 16.3 months) matches with the low risk of restenosis obtained by other groups [7, 20, 21]. All 3 of the 38 patients (7.9%) who required treatment for early arch hypoplasia or stenosis had documented arch hypoplasia preoperatively. The hypoplasia of the arch just distal to the offshoot of the brachiocephalic trunk is surgically unreachable using the clamp and sew technique because of the space occupied by the proximal clamp. Considering that in 27 patients with variable degree of arch hypoplasia only 3 needed subsequent intervention suggests that if extended resection and direct anastomosis is performed early and correctly, this part of the aorta has the potential for rapid adaptation without resulting in any significant gradient [22].
Coarctation of the aorta is commonly associated with simple or complex cardiovascular defects at birth. At the beginning of our experience, we had favored complete correction of cardiovascular defects in one session through a sternotomy, as advocated by other groups [23]. However, with the development of our minimally invasive approach, we have switched back to a staged correction. In patients with a single ventricular septal defect, we prefer not to band the pulmonary artery, and we correct the ventricular septal defect 2 to 6 weeks later through a partial inferior sternotomy [24]. In patients with associated complex cardiac anomalies (multiple muscular ventricular septal defects, complex transposition of great arteries such as with intramural coronary artery or hypoplastic right ventricle), we band the pulmonary artery to gain time before definitive correction. We believe that this approach helps to significantly ameliorate the risk of a simultaneous complex correction at a neonatal age. However, we would perform a single-stage repair if we believe that the proximal aortic arch hypoplasia is likely to result in significant gradients postoperatively.
In conclusion, a less invasive approach involving a muscle-sparing posterior minithoracotomy and an extrapleural approach for the repair of aortic coarctation in early infancy is feasible and safe. It provides adequate exposure of the aortic isthmus and arch and allows excellent repair. This approach reduces trauma caused by handling of the lung and better restores the normal anatomy of the intercostal space. Prospects of achieving surgical results comparable to the existing gold standard while minimizing trauma during approach, and of achieving an early cure of proximal hypertension, make this management strategy appealing, especially at a time when cardiologists are tempted by percutaneous approaches.
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Abstract
Introduction
