There are many techniques to repair aortic coarctation, and each has advantages and disadvantages in accomplishing relief of the aortic obstruction with the lowest mortality and chance of recurrence. No single technique is superior for use in all patients.
20-1. Resection and Primary Anastomosis
This repair is historically the gold standard to which to compare the results of other techniques, although it may require a more extensive dissection to mobi- lize the arch and the descending aorta for adequate length of aortic segments used in the primary repair. When this operation is performed in small infants, the recurrence rate is higher at some centers, but it continues to be my preferred operation for use in children beyond infancy. Use of the extended end-to-end anastomosis may help to avoid recurrence. After resection of the coarctation, the upper aortic segment is incised longitudinally along the inferior surface of the arch while the lateral descending aorta is incised. This results in an oblique anas- tomosis that is usually longer than the aortic diameter.
FIGURE 20-1. Working through a left thoracotomy, the parietal pleura is incised and the vagus and recurrent nerves are reflected toward the medi- astinum. Dissection is per- formed around the distal arch, left subclavian artery, ductus arteriosus, and upper half of the descending aorta.
left subclavian artery patent ductus arteriosus coarctation
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ductus stump
aortic arch left subclavian artery anastomosis
FIGURE
20-2. The ductus arteriosus is doubly clamped, divided, and the pulmonary artery end is closed. Vascular clamps are applied to the aorta. The aorta, ductal stump and coarc- tation are resected. An end-to-end anastomosis is performed with a continuous over-and- over suture in the posterior row. Interrupted mattress sutures are used to construct the anterior anastomosis. The anastomosis incorporates the base of the subclavian artery, as well as the distal arch because of a size discrepancy between the upper and lower aortic segments. Alternatively, and used in most cases, an extended end-to-end anastomosis is performed by incising longitudinally the inferior surface of the arch up to the level of the left carotid artery. The opened lower aorta is incised longitudinally on its lateral aspect, after which a direct anastomosis is performed between the aortic segments. The resulting suture line is longer than the diameter of the aorta.
coarctation
FIGURE
20-3. The resected specimen reveals a severe aortic narrowing.
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patent ductus arteriosus aortic arch left subclavian artery hypoplastic isthmus
FIGURE
20-4. In another patient with a typical preductal coarctation, the aortic isthmus is hypoplastic.
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aortic arch
left subclavian artery anastomosis
FIGURE 20-5. The repair includes ductal division and closure of the pulmonary artery end of that structure. The hypoplastic aorta and discrete coarctation are resected. An end-to- end anastomosis is performed between the two aortic segments with a size discrepancy.
The proximal aorta may be incised to the region of the mid arch if the arch is hypoplas-
tic, and an extended end-to-end anastomosis performed.
20-2. Subclavian Artery Flap Angioplasty
This is the preferred operation for small infants. It can be performed rapidly, with less dissection and a simple and predictable anastomosis. Relief of the aortic obstruction is excellent, and recurrence is rare because the aortic suture is not circumferential.
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aortic arch
left subclavian artery hypoplastic isthmus
area of coarctation
FIGURE
20-6. Working through a left thoracotomy, the parietal pleura is incised and the nerves are reflected anteriorly. The left subclavian artery and distal arch are dissected. The descending aorta is freed only a short distance beyond the ductus or ligamentum.
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coarctation
FIGURE
20-7. The distal left subclavian artery is ligated immediately beyond the vertebral
artery, which is ligated separately. Leaving some distal branches to intercommunicate
results in improved left arm perfusion. Snares are pulled tight around the distal arch and
the upper descending aorta. The aorta is incised below the coarctation and this incision is
extended cephalad across the isthmus and the subclavian artery. If the ductus is patent it
is closed with a hemoclip.
subclavian artery flap
1; *****'
transverse incision at lower extreme of aortotomy
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FIGURE
20-8. The subclavian artery is divided distally immediately proximal to the liga- ture and the artery flap is moved caudad for anastomosis over the aortotomy. The lower end of the aortotomy has been opened transversely in T fashion, resulting in a larger aortic lumen distally after completion of the anastomosis.
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subclavian artery flap
FIGURE
20-9. The flap is anastomosed to the aorta with a continuous fine monofilament
suture.
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hemoclip on ductus subclavian artery flap
FIGURE
20-10. The completed repair includes an adequate aortic lumen composed of endogenous and viable aortic tissue without a circumferential aortic suture line. The aorta should grow at the site of the previous coarctation, resulting in less chance of recurrence.
The lower end of the flap is wide, resulting in a larger aortic lumen caudad to the coarc- tation shelf.
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FIGURE
20-11. In another baby in whom the lower end of the aortic incision is not opened
in T fashion, the distal part of the flap is narrow, and there is a chance of residual
obstruction.
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distal arch left subclavian artery ductus arteriosus anomalous right subclavian artery
coarctation
FIGURE
20-12. In another infant, an anomalous right subclavian artery arises from the aortic isthmus.
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distal arch left subclavian artery ductus arteriosus
subclavian artery flap
FIGURE
20-13. The right subclavian artery is dissected in the mediastinum and is ligated
distally. The ductus arteriosus is ligated. The right subclavian artery is divided, and an inci-
sion is made along its proximal part and onto the upper descending thoracic aorta to a
point beyond the coarctation. The anomalous right subclavian artery flap is moved to a
caudad position for anastomosis over the aortotomy.
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subclavian artery flap
FIGURE
20-14. The flap repair is more posterior but is adequate to relieve the obstruction.
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left subclavian artery
coarctation
FIGURE
20-15. In another infant, the coarctation is located between the left common
carotid and left subclavian arteries.
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left carotid artery subclavian artery reverse flap
FIGURE
20-16. A reverse subclavian artery flap is performed. The left subclavian artery is divided distally and then incised proximally along its medial border. This incision extends across the arch coarctation and onto the base of the left carotid artery. The subclavian artery flap is shifted medially and anastomosed over the aortotomy using a continuous suture.
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aortic arch left carotid artery subclavian artery reverse flap
FIGURE
20-17. The completed repair shows the reverse flap.
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left carotid artery hypoplastic arch left subclavian artery
ductus arteriosus coarctation
FIGURE
20-18. In another infant, there is severe hypoplasia of the distal aortic arch beyond the left common carotid artery and, in addition, an isthmic coarctation.
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patent ductus arteriosus left carotid artery
subclavian artery reverse flap coarctation
FIGURE
20-19. The hypoplastic arch is repaired with a left subclavian artery reverse flap.
During this part of the surgery, the ductus remains patent and supplies blood to the lower
aorta.
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ductus stump
Gore-Tex patch
FIGURE
20-20. The ductus arteriosus is divided and each end is oversewn. A Gore-Tex®
patch is then stitched over a long aortotomy made from the subclavian artery flap and across the isthmus.
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left subclavian artery reverse flap
FIGURE
20-21. The reverse flap and Gore-Tex® patch are visualized.
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distal arch
area of recurrent coarctation
FIGURE
20-22. In another infant, who previously underwent subclavian artery flap angio- plasty, a recurrence occurred requiring repeat surgery 1 year later. Alternatively, balloon dilatation can be performed as an invasive cardiology procedure.
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recurrent coarctation
FIGURE
20-23. Repair is performed using synthetic patch angioplasty. A longitudinal aor-
totomy is made from the distal arch, across the recurrent stenosis, and onto the upper
descending thoracic aorta.
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patch
FIGURE
20-24. A Dacron® patch is stitched over the aortotomy to relieve the obstruction.
Alternatively, a Gore-Tex® patch may be used.
20-3. Subclavian Artery Translocation Angioplasty
This operation can be performed at any age, but is simpler to carry out in an older child with a larger aorta and subclavian artery. Extensive dissection of the left subclavian artery and its branches is necessary, as is dissection of much of the thoracic aorta. The repair uses viable tissue without the need for a circumferen- tial suture line. Normal blood flow through the subclavian artery is preserved.
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aortic arch
Internal mammary artery left subclavian artery vertebral artery coarctation
FIGURE
20-25. The distal aortic arch, left subclavian artery and its branches, and descend-
ing thoracic aorta are widely dissected. The ligamentum arteriosum or ductus arteriosus
is divided for maximal aortic mobilization.
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left subclavian artery vertebral artery
FIGURE
20-26. Mobilization of the subclavian artery is accomplished by dissecting all branches of this vessel at the thoracic inlet.
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coarctation
left subclavian artery patch
FIGURE
20-27. The subclavian artery is divided at its origin from the aorta, and the medial
aspect is incised to near the origin of the vertebral artery. The aortotomy is extended
caudad to a point beyond the coarctation. The proximal subclavian artery is shifted caudad
and the opened artery is anastomosed to the large aortotomy. The posterior anastomosis
is performed, first working within the lumen of the aorta.
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distal arch distal left subclavian artery subclavian artery patch
FIGURE
20-28. The anterior anastomosis completes the repair. The subclavian artery is intact but has been shifted caudad. Its wide base overlies the area of the coarctation, sig- nificantly enlarging the aorta at that site.
20-4. Dacron® Patch Angioplasty
Advantages of this operation include its simplicity, without the need for exten- sive aortic dissection, and relief of the aortic obstruction is usually successful. This repair is used only as a last resort, when other repairs are not applicable because of the late complication of aneurysm formation in a significant number of patients.
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aortic arch
left subclavian artery coarctation
FIGURE
20-29. The pleura is incised and the nerves are reflected medially. The distal arch,
proximal left subclavian artery, and upper thoracic aorta are dissected.
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coarctation
FIGURE
20-30. An incision is made from the base of the subclavian artery across the coarc- tation and into the descending thoracic aorta.
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Dacron patch
FIGURE
20-31. The repair is completed by suturing a Dacron® patch over the aortotomy.
A Gore-Tex® patch may be used as an alternative.
FIGURE
20-32. In this child, 7 years after initial Dacron® patch angioplasty, an aneurysm was suspected after examining a plain chest film. The angiogram reveals a large aortic dilatation into the base of the left subclavian artery.
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tape around arch aneurysm
descending aorta
FIGURE
20-33. At surgery a large thoracic aneurysm is found. The aorta is mobilized for
proximal and distal control. Repair is performed with partial cardiopulmonary bypass and
exclusion of the aneurysm between aortic clamps. One cannula for venous return to the
pump is placed in the left atrial appendage, and the arterial perfusion cannula is placed
in the descending thoracic aorta. Normal flow from the functioning left ventricle will
perfuse the head and right subclavian artery.
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aneurysm sac
FIGURE
20-34. After establishing partial bypass and then excluding the aneurysm between vascular clamps, the thin-walled aneurysm is entered.
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Dacron patch
FIGURE
20-35. After opening the aneurysm widely, intercostal vessels entering the sac are
oversewn. The previously placed Dacron® patch is seen in the posterior sac.
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left subclavian artery graft aortic graft
FIGURE
20-36. A woven tubular Dacron® conduit is inserted within the aneurysm to replace the aorta. A smaller conduit as a side arm replaces the proximal left subclavian artery.
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FIGURE
