Ann Thorac Surg 2006;81:1428
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Frank M. Midgley, MD
CV Surgery (Pediatrics), The Milton S. Hershey Medical Center, 10920 Cripplegate Rd, Potomac, MD 20854
(Email: drfrank1092{at}aol.com).
Since its introduction by Waldhausen in 1966, subclavian flap aortoplasty (SFA) has served as an effective operative modality for infant coarctation of the aorta. As with all abnormalities with multiple, possible methods of repair, its place as a primary operation has been determined by anatomy, surgeon's preference, and follow-up studies.
The major benefits of SFAs have been the lack of a circumferential suture line, the ability to augment tension-free, long segments of aortic isthmic hypoplasia, and the very real potential for growth of the native tissue flapped into the hypoplastic areas.
Detracting elements have been the fact that native coarctation tissue is left in-situ, possibly influencing re-coarctation. There may also be long-term vascular consequences in the ipselateral extremity due to the division of the subclavian artery. As to this potential vascular issue, it should be appreciated that the interruption of vascular supply to the arm by the division of the subclavian artery is far less an insult than was routinely accepted with the classic Blalock-Taussig shunt in which the subclavian plus multiple distal vessels (internal mammary, thyrocervical trunk, and so forth) that participated in the collateral circulation around the shoulder were interrupted without apparent consistent severe changes to the development of the arm. As indicated in this article [1], the changes seen with SFA are minimal in limitation to the forearm, and they are asymptomatic.
Recoarctation, in most surgeon's experience, when properly selected is as uncommon as with resection/reanastomosis or prosthetic patch aortoplasty, about 5%. Most can be successfully treated by balloon angioplasty in the cath laboratory.
Mortality would seem to be related more to the presence of additional abnormalities than to the technique of repair. It should be 0% in uncomplicated cases.
With the "wisdom" of follow-up, it would seem that SFA represents an excellent method of repair in the small infant that has a well developed subclavian artery and has a long hypoplastic isthmus.
 |
References
|
|---|
- Pandey R, Jackson M, Ajab S, Gladman G, Pozzi M. Subclavian flap repairreview of 399 patients at median follow-up of 14 years. Ann Thorac Surg 2006;81:1420-1428.[Abstract/Free Full Text]
Top
References