Coarctation Repair in Neonates With Subclavian= Sparing Advancement Flap Baljit K. Sharma, MD, Moises Calderon, MD, and David A. Ott, MD Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
A modification of the technique of using the subclaviansparing advancement flap for severe coarctation of the aorta was successfully used in 7 neonates ranging in age from 3 to 30 days (mean age, 12 days). Four of the 7 patients had associated cardiac defects with congestive heart failure. The procedure was performed through a left thoracotomy incision, and the coarctation repair was performed by advancing the origin of the left subclavian artery as a flap while preserving flow to the left arm. No deaths occurred, and there was patency of the repair in all patients at follow-up ranging from 1% to 2% years (mean, 2 years). In 7 of the 8 patients there was no clinically significant gradient either by examination or Doppler echocardiography at follow-up. One patient
underwent balloon angioplasty at the time of catheterization to evaluate other cardiac defects 1year postoperatively, at which time he was noted to have a peak systolic gradient of 30 mm Hg across the repair site. The technique of subclavian-sparing advancement is a reasonable addition to the surgical armamentarium for coarctation repair in neonates. It provides the advantages of subclavian flap aortoplasty without sacrificing the blood supply to the left arm. Because of the unique anatomic variations associated with coarctation of the aorta, we suggest that the choice of repair be individualized for patients with this condition.
N
anastomosis in one. Thus the advancement flap technique was used in about one third of all neonates who required operation for coarctation during the period of the study. The group comprised 5 male and 2 female patients, ranging in age from 3 days to 30 days (mean age, 12 days). All patients were admitted with severe congestive heart failure requiring decongestive therapy. None of the patients was hypertensive. A systolic murmur was present in 5. The femoral pulses were absent in 3 patients, markedly reduced in 2, and palpable in 2. The chest roentgenogram was within normal limits in all patients. Electrocardiographic studies showed normal sinus rhythm in all patients, with right ventricular hypertrophy in 5, biventricular hypertrophy in 1, and left ventricular hypertrophy in 1. Echocardiography confirmed the diagnosis of coarctation in all patients. The associated lesions are listed in Table 1. Cardiac catheterization was performed in 3 patients preoperatively and in the immediate postoperative period in another patient who continued to have congestive heart failure after coarctation repair. One patient underwent balloon dilation for coarctation at 5 days of age. After an initial transient improvement, his femoral pulses disappeared, and coarctation repair was performed. All patients were followed up in the clinic after operation with Doppler echocardiographic studies, physical examination, and cuff blood pressure measurements. One patient had a repeat catheterization 1 year after repair before undergoing definitive correction of transposition of the great arteries, and another for evaluation of his ventricular septa1 defect and pulmonary artery banding and residual hypertension. The operative technique used was almost identical to the one described by de Mendonqa and associates [ 8 , 9 ] . A
eonates with severe coarctation of the aorta usually have various other associated congenital cardiac defects and are seen early in life with congestive heart failure. Whereas surgical correction is the accepted form of treatment, the choice of surgical procedure remains controversial. A high incidence of restenosis occurring after resection and end-to-end anastomosis [l] in this age group has prompted the application of alternative procedures such as synthetic patch aortoplasty [2, 31 and subclavian flap aortoplasty [4] (SFA), which is perhaps the most commonly used procedure for coarctation repair in neonates. This procedure can be performed with low mortality and a low incidence of restenosis. However, it has the inherent disadvantage of loss of blood supply to the left arm, with the rare but potential sequelae that accompany this complication [5-71. The technique of the subclavian advancement flap as described by de Mendonla and associates [8] incorporates the benefits of SFA without sacrificing blood supply to the left arm. We report here a retrospective analysis of our results using a slight modification of this technique in 7 neonates.
Patients and Methods Between July 1988 and March 1991, 7 neonates ( 5 3 0 days of age) underwent coarctation repair with subclavian advancement by Dr Ott. During the same period 17 other neonates underwent repair by the same surgeon using the classic subclavian flap technique in 16 and end-to-end Accepted for publication Dec 27, 1991. Address reprint requests to Dr Ott, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.
0 1992 by The Society of Thoracic Surgeons
(Ann Thoruc Surg 1992;54:13741)
0003-4975/92/$5.00
138
Ann Thorac Surg 1992;54:13741
SHARMA ET AL COARCTATION REPAIR IN NEONATES
Table 1. Associated Lesions" Patient No. 1 2
3
4 5 6 7
Associated Lesions PDA, MR, PFO Mitral atresia, VSD, DORV, PDA, hypoplastic aortic
isthmus VSD, TGA, PDA, PFO with narrow isthmus of the aorta
PDA, PFO, bicuspid aortic valve, MR, TR VSD, PDA VSD, PDA, bicuspid aortic valve PDA, bicuspid aortic valve
All patients underwent ligation of the persistent ductus arteriosus with subclavian advancement. In addition, pulmonary artery banding was done in patients 2, 3, and 5. a
DORV = double-outlet right ventricle; MR = mitral regurgitation; PFO = patent foramen ovale; PDA = persistent ductus arteriosus; TGA = transposition of the great arteries; TR = tricuspid regurgitation; VSD = ventricular septa1 defect.
left thoracotomy was made, and the chest was entered through the third left intercostal space. After ligation and division of the persistent ductus arteriosus, the aorta and the left subclavian artery were mobilized. Before the incisions were made, the subclavian artery was brought down to the coarctation site to ensure adequate length without undue tension on the anastomosis. Thereafter, the origin of the subclavian artery was detached, and the aorta was opened across the site of coarctation. The ductal shelf was completely excised, and the origin of the subclavian was advanced to create a flap over the coarcted segment of the aorta. The anastomosis was performed with a continuous 5-0 polydioxanone suture or 6-0 polypropylene suture (Fig 1).In no patient did aortic crossclamp time exceed 15 minutes. The operative procedures were individualized for each patient based on the pres-
Fig 1 . Illustration of the subclaziian-sparing advance-
ment flap technique. See text for details of the procedure.
Fig 2 . Preoperative aiigiogram illustrating aortic COarCtatiOn ence of associated cardiac defects (see Table 1). When indicated, pulmonary artery banding was performed after the coarctation repair. Preoperative and postoperative views from a representative case are illustrated in Figures 2 and 3.
Results No deaths occurred during a follow-up period ranging from 4 months to 2 years. Postoperatively, all patients had
SHARMA ET AL COARCTATION REPAIR IN NEONATES
Ann Thorac Surg 1992;54:13741
139
Table 2. Catheterization Data From the Patient Who Underwent Balloon Anaiowlastu After Coarctation Rewair Location Ascending aorta Descending aorta a
Fig 3. Postoperative angiogram after coarctation repair (from patient in Figure 2).
palpable left radial pulses and femoral artery pulses. Early postoperative echocardiography revealed no evidence of residual coarctations. One patient (patient 6) continued to have severe congestive heart failure in the postoperative period and required surgical closure of a nonrestrictive muscular ventricular septal defect 2 weeks after the initial coarctation repair. The patient then had an uneventful recovery. Another patient who had a concomitant pulmonary artery banding at the time of coarctation repair had development of a pericardial effusion, which responded to medical management. Follow-up was obtained in all patients and included examination by the attending cardiologist at Texas Children’s Hospital, at which time echocardiographic evaluation with Doppler flow studies were obtained. Length of follow-up ranged from 1% to 2% years. Mean length of follow-up was 2 years. In 7 of the 8 patients (87.5%) no pressure gradient was noted between the upper and lower extremities by blood pressure cuff examination. Doppler flows were less than 2 m/s in these 7 patients. One patient had a Doppler flow of 2.7 m/s and had mild systemic hypertension 1 year postoperatively. He underwent cardiac catheterization to evaluate his ventricular septal defect and previously placed pulmonary artery band and to evaluate the coarctation repair. A peak systolic gradient of 30 mm Hg was noted, and balloon angioplasty was performed, reducing the gradient to 10 mm Hg. Data from that catheterization and one from 1 year after the balloon angioplasty are shown in Table 2.
Comment Since Crafoord and Nylin [lo] described the technique of resection and end-to-end anastomosis in 1945, this method has been the standard for repair of coarctation. Resection and end-to-end anastomosis preserves the blood supply to the left arm. Korfer and co-workers [ll]
Before Angioplasty
Angioplasty
After
1 Year After
(mm Hg)
(mm Hg)
(mm HF.9
110150 (66)” 80150 (65)
105145 (52) 95/50
122168 (92) 122168 (92)
Angioplasty
Values in parentheses are mean pressure.
have reported good results with use of this technique in neonates. Concern regarding growth of a circumferential suture line and incomplete excision of the narrowed segment of the aorta or a narrow isthmus resulting in restenosis [l]led to the development of alternative procedures. As experience with the arterial switch procedure has grown, it appears that the concern over growth of the circumferential suture line may have been unfounded [121. To overcome the problem of a narrow isthmus, Lansman and colleagues [13] described extended aortic arch anastomosis for repair of coarctation in infancy, and they reported excellent results with this method. However, many intercostal vessels have to be sacrificed to adequately mobilize the aorta, thus increasing the potential of postoperative bleeding and neurological complications with this procedure. Prosthetic patch aortoplasty avoids circular constrictive anastomosis with no tension on the anastomosis, requires little or no mobilization of the aorta, and can be performed easily and rapidly. Good results have been reported with this technique [2, 31. In a comparative study of patch aortoplasty with resection and end-to-end anastomosis, Hesslein and associates [14] found no difference with either technique. However, the potential hazards of implanted foreign material, including degeneration and aneurysmal formation, in as many as 67% of patients with follow-up reduce the attractiveness of this method [15]. Subclavian flap aortoplasty as described by Waldhausen and Nahrwold [4] has the advantage of autogenous tissue with potential for growth and provides a noncircumferential, nonconstricting suture line that reduces the incidence of restenosis and provides a more definitive repair of the narrowed isthmus. Subclavian flap aortoplasty is perhaps the most commonly performed procedure for coarctation in neonates and infants. With the procedure, excellent long-term results have been reported [16, 171. In comparing the technique of SFA with resection and end-to-end anastomosis, Palatianos and associates [18] found SFA to be superior, whereas Fenchel and co-workers [19] found no difference in results with either procedure. Cobanoglu and colleagues [20] found resection and end-to-end anastomosis to be better than SFA. However, the decrease in blood supply to the left arm with the classic subclavian flap technique can result in ischemia, growth retardation of the left arm, or compromised hemodynamics with the potential for ischemia during exercise [5-111. Mellgren and associates [21]reported ischemic complications in 2 of
140
SHARMA ET AL COARCTATION REPAIR IN NEONATES
34 patients, necessitating amputation of the left arm i n 1 and amputations of first and third digits i n another. Advancement of the origin of the subclavian artery to relieve the obstruction, a s originally described by de Mendonga and associates [8], theoretically retains all the advantages of SFA without sacrificing blood supply to the left arm. In a recent report, Ladusans and colleagues [22] described recurrence of aortic coarctation after repair by reimplantation of t h e subclavian artery within 6 m o n t h s i n all 4 of their patients. Our experience w i t h 7 neonates w i t h a longer follow-up suggests that w i t h proper excision of the ductal shelf and creation of a longer subclavian flap, excellent results c a n be achieved i n selected neonates and infants with the subclavian-sparing advancement technique.
The debate regarding which surgical procedure is best for repair of coarctation will probably never be resolved. The ideal procedure should relieve the coarctation, should be easy to perform w i t h few complications a n d a low incidence of restenosis, and should cause no vascular impairment i n the left arm. Our experience leads us to believe that the subclavian-sparing advancement procedure is an excellent technique for repair of coarctations i n neonates and infants i n those patients i n w h o m it is technically feasible. In retrospect the technique could probably have been used i n a h i g h percentage of patients i n this series. Rather than trying to settle on one procedure that will be used for every patient, we suggest maintaining a working knowledge of the four alternative operations and tailoring the selection to individual patients, d e p e n d i n g on the anatomic variables inherent i n the spectrum of coarctation.
Ann Thorac Surg
1992;54: 1 3 7 4 1
effects on the upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1982;84:779-82. 7. Lodge FA, Lamberti JJ, Goodman AH, et al. Vascular consequences of subclavian artery transection for the treatment of congenital heart disease. J Thorac Cardiovasc Surg 1983;86: 1S23. 8. De Mendonfa JT, Carvalho MR, Costa RK, Filho EF. Coarctation of the aorta: a new surgical technique. J Thorac Cardiovasc Surg 1985;90:445-7. 9. Meier MA, Lucchese FA, Jazbik W, Nesralla IA, de Mendonfa JT. A new technique for repair of aortic coarctation: subclavian flap aortoplasty with preservation of arterial blood flow to the left arm. J Thorac Cardiovasc Surg 1986;92: 1005-12. 10. Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:347-61. 11. Korfer R, Meyer H, Kleikamp G, Bircks W. Early and late results after resection and end-to-end anastomosis of coarctation of the thoracic aorta in early infancy. J Thorac Cardio12.
13. 14.
15. 16.
17. 18.
References 1. Williams WG, Shindo G, Trusler GA, Dische MR, Olley PM. Results of repair of coarctation of the aorta during infancy. J Thorac Cardiovasc Surg 1980;79:603-8. 2. Vosschulte K. Surgical correction of coarctation of the aorta by an "isthmusplastic" operation. Thorax 1961;16:33845. 3. Reul GJ Jr, Kabbani SS, Sandiford FM, Wukasch DC, Cooley DA. Repair of coarctation of the thoracic aorta by patch graft aortoplasty. J Thorac Cardiovasc Surg 1974;68:696-704. 4. Waldhausen JA, Nahrwold DL. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532-3. 5. Geiss D, Williams WG, Lindsay WK, Rowe RD. Upper extremity gangrene: a complication of subclavian artery division. Ann Thorac Surg 1980;30:487-9. 6. Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late
19.
20.
21.
22.
H, Lange P, et al. Assessment of coronary and aortic anastomosis after anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1985;90:597404. Lansman S, Shapiro AJ, Schiller MS, et al. Extended aortic arch anastomosis for repair of coarctation in infancy. Circulation 1986;74(Suppl1):3741. Hesslein PS, McNamara DG, Morriss MJH, Hallman GL, Cooley DA. Comparison of resection versus patch aortoplasty for repair of coarctation in infants and children. Circulation 1981;64:164-8. Del Nido PJ, Williams WG, Wilson GJ, et al. Synthetic patch angioplasty for repair of coarctation of the aorta: experience with aneurysm formation. Circulation 1986;74(Suppl1):324. Bergdahl LAL, Blackstone EH, Kirklin JW, Pacific0 AD, Bargeron LM Jr. Determinants of early success in repair of aortic coarctation in infants. J Thorac Cardiovasc Surg 1982; 83:736-42. Penkoske PA, Williams WG, Olley PM, et al. Subclavian arterioplasty: repair of coarctation of the aorta in the first year of life. J Thorac Cardiovasc Surg 1984;87894-900. Palatianos GM, Thurer RJ, Kaiser GA. Comparison of operations for coarctation of the aorta in infants. J Cardiovasc Surg 1987;28:128-31. Fenchel G, Steil E, Seybold-Epting W, Seboldt H, Apitz J, Hoffmeister HE. Repair of symptomatic aortic coarctation in the first three months of life: early and late results after resection and end-to-end anastomosis and subclavian flap angioplasty. J Cardiovasc Surg 1988;29:257-63. Cobanoglu A, Teply JF, Grunkemeier GL, Sunderland CO, Starr A. Coarctation of the aorta in patients younger than three months: a critique of the subclavian flap operation. J Thorac Cardiovasc Surg 1985;89:128-35. Mellgren G, Friberg LG, Erikeson BO, Sabel KG, Mellander M. Neonatal surgery for coarctations of the aorta: the Gothenburg experience. Scand J Thorac Cardiovasc Surg 1987;21: 193-7. Ladusans EJ, Campalani G, Parsons JM, et al. Recurrence of aortic coarctation following repair of re-implantation of the subclavian artery. Int J Cardiol 1989;23:321-5.
INVITED COMMENTARY It is now almost half a century since Crafoord first repaired a coarctation of the aorta i n a child by resecting the n a r r o w segment and performing an end-to-end anastomosis. Since then many operations have been devised
with n u m e r o u s publications extolling t h e virtues of a given operation. This w o u l d suggest that, perhaps, no operation really solves the problem and t h a t we m u s t continue t o search for the ideal repair of coarctation of the
A modification of the technique of using the subclaviansparing advancement flap for severe coarctation of the aorta was successfully used in 7 neonates ranging in age from 3 to 30 days (mean age, 12 days). Four of the 7 patients had associated cardiac defects with congestive heart failure. The procedure was performed through a left thoracotomy incision, and the coarctation repair was performed by advancing the origin of the left subclavian artery as a flap while preserving flow to the left arm. No deaths occurred, and there was patency of the repair in all patients at follow-up ranging from 1% to 2% years (mean, 2 years). In 7 of the 8 patients there was no clinically significant gradient either by examination or Doppler echocardiography at follow-up. One patient
underwent balloon angioplasty at the time of catheterization to evaluate other cardiac defects 1year postoperatively, at which time he was noted to have a peak systolic gradient of 30 mm Hg across the repair site. The technique of subclavian-sparing advancement is a reasonable addition to the surgical armamentarium for coarctation repair in neonates. It provides the advantages of subclavian flap aortoplasty without sacrificing the blood supply to the left arm. Because of the unique anatomic variations associated with coarctation of the aorta, we suggest that the choice of repair be individualized for patients with this condition.
N
anastomosis in one. Thus the advancement flap technique was used in about one third of all neonates who required operation for coarctation during the period of the study. The group comprised 5 male and 2 female patients, ranging in age from 3 days to 30 days (mean age, 12 days). All patients were admitted with severe congestive heart failure requiring decongestive therapy. None of the patients was hypertensive. A systolic murmur was present in 5. The femoral pulses were absent in 3 patients, markedly reduced in 2, and palpable in 2. The chest roentgenogram was within normal limits in all patients. Electrocardiographic studies showed normal sinus rhythm in all patients, with right ventricular hypertrophy in 5, biventricular hypertrophy in 1, and left ventricular hypertrophy in 1. Echocardiography confirmed the diagnosis of coarctation in all patients. The associated lesions are listed in Table 1. Cardiac catheterization was performed in 3 patients preoperatively and in the immediate postoperative period in another patient who continued to have congestive heart failure after coarctation repair. One patient underwent balloon dilation for coarctation at 5 days of age. After an initial transient improvement, his femoral pulses disappeared, and coarctation repair was performed. All patients were followed up in the clinic after operation with Doppler echocardiographic studies, physical examination, and cuff blood pressure measurements. One patient had a repeat catheterization 1 year after repair before undergoing definitive correction of transposition of the great arteries, and another for evaluation of his ventricular septa1 defect and pulmonary artery banding and residual hypertension. The operative technique used was almost identical to the one described by de Mendonqa and associates [ 8 , 9 ] . A
eonates with severe coarctation of the aorta usually have various other associated congenital cardiac defects and are seen early in life with congestive heart failure. Whereas surgical correction is the accepted form of treatment, the choice of surgical procedure remains controversial. A high incidence of restenosis occurring after resection and end-to-end anastomosis [l] in this age group has prompted the application of alternative procedures such as synthetic patch aortoplasty [2, 31 and subclavian flap aortoplasty [4] (SFA), which is perhaps the most commonly used procedure for coarctation repair in neonates. This procedure can be performed with low mortality and a low incidence of restenosis. However, it has the inherent disadvantage of loss of blood supply to the left arm, with the rare but potential sequelae that accompany this complication [5-71. The technique of the subclavian advancement flap as described by de Mendonla and associates [8] incorporates the benefits of SFA without sacrificing blood supply to the left arm. We report here a retrospective analysis of our results using a slight modification of this technique in 7 neonates.
Patients and Methods Between July 1988 and March 1991, 7 neonates ( 5 3 0 days of age) underwent coarctation repair with subclavian advancement by Dr Ott. During the same period 17 other neonates underwent repair by the same surgeon using the classic subclavian flap technique in 16 and end-to-end Accepted for publication Dec 27, 1991. Address reprint requests to Dr Ott, Texas Heart Institute, PO Box 20345, Houston, TX 77225-0345.
0 1992 by The Society of Thoracic Surgeons
(Ann Thoruc Surg 1992;54:13741)
0003-4975/92/$5.00
138
Ann Thorac Surg 1992;54:13741
SHARMA ET AL COARCTATION REPAIR IN NEONATES
Table 1. Associated Lesions" Patient No. 1 2
3
4 5 6 7
Associated Lesions PDA, MR, PFO Mitral atresia, VSD, DORV, PDA, hypoplastic aortic
isthmus VSD, TGA, PDA, PFO with narrow isthmus of the aorta
PDA, PFO, bicuspid aortic valve, MR, TR VSD, PDA VSD, PDA, bicuspid aortic valve PDA, bicuspid aortic valve
All patients underwent ligation of the persistent ductus arteriosus with subclavian advancement. In addition, pulmonary artery banding was done in patients 2, 3, and 5. a
DORV = double-outlet right ventricle; MR = mitral regurgitation; PFO = patent foramen ovale; PDA = persistent ductus arteriosus; TGA = transposition of the great arteries; TR = tricuspid regurgitation; VSD = ventricular septa1 defect.
left thoracotomy was made, and the chest was entered through the third left intercostal space. After ligation and division of the persistent ductus arteriosus, the aorta and the left subclavian artery were mobilized. Before the incisions were made, the subclavian artery was brought down to the coarctation site to ensure adequate length without undue tension on the anastomosis. Thereafter, the origin of the subclavian artery was detached, and the aorta was opened across the site of coarctation. The ductal shelf was completely excised, and the origin of the subclavian was advanced to create a flap over the coarcted segment of the aorta. The anastomosis was performed with a continuous 5-0 polydioxanone suture or 6-0 polypropylene suture (Fig 1).In no patient did aortic crossclamp time exceed 15 minutes. The operative procedures were individualized for each patient based on the pres-
Fig 1 . Illustration of the subclaziian-sparing advance-
ment flap technique. See text for details of the procedure.
Fig 2 . Preoperative aiigiogram illustrating aortic COarCtatiOn ence of associated cardiac defects (see Table 1). When indicated, pulmonary artery banding was performed after the coarctation repair. Preoperative and postoperative views from a representative case are illustrated in Figures 2 and 3.
Results No deaths occurred during a follow-up period ranging from 4 months to 2 years. Postoperatively, all patients had
SHARMA ET AL COARCTATION REPAIR IN NEONATES
Ann Thorac Surg 1992;54:13741
139
Table 2. Catheterization Data From the Patient Who Underwent Balloon Anaiowlastu After Coarctation Rewair Location Ascending aorta Descending aorta a
Fig 3. Postoperative angiogram after coarctation repair (from patient in Figure 2).
palpable left radial pulses and femoral artery pulses. Early postoperative echocardiography revealed no evidence of residual coarctations. One patient (patient 6) continued to have severe congestive heart failure in the postoperative period and required surgical closure of a nonrestrictive muscular ventricular septal defect 2 weeks after the initial coarctation repair. The patient then had an uneventful recovery. Another patient who had a concomitant pulmonary artery banding at the time of coarctation repair had development of a pericardial effusion, which responded to medical management. Follow-up was obtained in all patients and included examination by the attending cardiologist at Texas Children’s Hospital, at which time echocardiographic evaluation with Doppler flow studies were obtained. Length of follow-up ranged from 1% to 2% years. Mean length of follow-up was 2 years. In 7 of the 8 patients (87.5%) no pressure gradient was noted between the upper and lower extremities by blood pressure cuff examination. Doppler flows were less than 2 m/s in these 7 patients. One patient had a Doppler flow of 2.7 m/s and had mild systemic hypertension 1 year postoperatively. He underwent cardiac catheterization to evaluate his ventricular septal defect and previously placed pulmonary artery band and to evaluate the coarctation repair. A peak systolic gradient of 30 mm Hg was noted, and balloon angioplasty was performed, reducing the gradient to 10 mm Hg. Data from that catheterization and one from 1 year after the balloon angioplasty are shown in Table 2.
Comment Since Crafoord and Nylin [lo] described the technique of resection and end-to-end anastomosis in 1945, this method has been the standard for repair of coarctation. Resection and end-to-end anastomosis preserves the blood supply to the left arm. Korfer and co-workers [ll]
Before Angioplasty
Angioplasty
After
1 Year After
(mm Hg)
(mm Hg)
(mm HF.9
110150 (66)” 80150 (65)
105145 (52) 95/50
122168 (92) 122168 (92)
Angioplasty
Values in parentheses are mean pressure.
have reported good results with use of this technique in neonates. Concern regarding growth of a circumferential suture line and incomplete excision of the narrowed segment of the aorta or a narrow isthmus resulting in restenosis [l]led to the development of alternative procedures. As experience with the arterial switch procedure has grown, it appears that the concern over growth of the circumferential suture line may have been unfounded [121. To overcome the problem of a narrow isthmus, Lansman and colleagues [13] described extended aortic arch anastomosis for repair of coarctation in infancy, and they reported excellent results with this method. However, many intercostal vessels have to be sacrificed to adequately mobilize the aorta, thus increasing the potential of postoperative bleeding and neurological complications with this procedure. Prosthetic patch aortoplasty avoids circular constrictive anastomosis with no tension on the anastomosis, requires little or no mobilization of the aorta, and can be performed easily and rapidly. Good results have been reported with this technique [2, 31. In a comparative study of patch aortoplasty with resection and end-to-end anastomosis, Hesslein and associates [14] found no difference with either technique. However, the potential hazards of implanted foreign material, including degeneration and aneurysmal formation, in as many as 67% of patients with follow-up reduce the attractiveness of this method [15]. Subclavian flap aortoplasty as described by Waldhausen and Nahrwold [4] has the advantage of autogenous tissue with potential for growth and provides a noncircumferential, nonconstricting suture line that reduces the incidence of restenosis and provides a more definitive repair of the narrowed isthmus. Subclavian flap aortoplasty is perhaps the most commonly performed procedure for coarctation in neonates and infants. With the procedure, excellent long-term results have been reported [16, 171. In comparing the technique of SFA with resection and end-to-end anastomosis, Palatianos and associates [18] found SFA to be superior, whereas Fenchel and co-workers [19] found no difference in results with either procedure. Cobanoglu and colleagues [20] found resection and end-to-end anastomosis to be better than SFA. However, the decrease in blood supply to the left arm with the classic subclavian flap technique can result in ischemia, growth retardation of the left arm, or compromised hemodynamics with the potential for ischemia during exercise [5-111. Mellgren and associates [21]reported ischemic complications in 2 of
140
SHARMA ET AL COARCTATION REPAIR IN NEONATES
34 patients, necessitating amputation of the left arm i n 1 and amputations of first and third digits i n another. Advancement of the origin of the subclavian artery to relieve the obstruction, a s originally described by de Mendonga and associates [8], theoretically retains all the advantages of SFA without sacrificing blood supply to the left arm. In a recent report, Ladusans and colleagues [22] described recurrence of aortic coarctation after repair by reimplantation of t h e subclavian artery within 6 m o n t h s i n all 4 of their patients. Our experience w i t h 7 neonates w i t h a longer follow-up suggests that w i t h proper excision of the ductal shelf and creation of a longer subclavian flap, excellent results c a n be achieved i n selected neonates and infants with the subclavian-sparing advancement technique.
The debate regarding which surgical procedure is best for repair of coarctation will probably never be resolved. The ideal procedure should relieve the coarctation, should be easy to perform w i t h few complications a n d a low incidence of restenosis, and should cause no vascular impairment i n the left arm. Our experience leads us to believe that the subclavian-sparing advancement procedure is an excellent technique for repair of coarctations i n neonates and infants i n those patients i n w h o m it is technically feasible. In retrospect the technique could probably have been used i n a h i g h percentage of patients i n this series. Rather than trying to settle on one procedure that will be used for every patient, we suggest maintaining a working knowledge of the four alternative operations and tailoring the selection to individual patients, d e p e n d i n g on the anatomic variables inherent i n the spectrum of coarctation.
Ann Thorac Surg
1992;54: 1 3 7 4 1
effects on the upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1982;84:779-82. 7. Lodge FA, Lamberti JJ, Goodman AH, et al. Vascular consequences of subclavian artery transection for the treatment of congenital heart disease. J Thorac Cardiovasc Surg 1983;86: 1S23. 8. De Mendonfa JT, Carvalho MR, Costa RK, Filho EF. Coarctation of the aorta: a new surgical technique. J Thorac Cardiovasc Surg 1985;90:445-7. 9. Meier MA, Lucchese FA, Jazbik W, Nesralla IA, de Mendonfa JT. A new technique for repair of aortic coarctation: subclavian flap aortoplasty with preservation of arterial blood flow to the left arm. J Thorac Cardiovasc Surg 1986;92: 1005-12. 10. Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg 1945;14:347-61. 11. Korfer R, Meyer H, Kleikamp G, Bircks W. Early and late results after resection and end-to-end anastomosis of coarctation of the thoracic aorta in early infancy. J Thorac Cardio12.
13. 14.
15. 16.
17. 18.
References 1. Williams WG, Shindo G, Trusler GA, Dische MR, Olley PM. Results of repair of coarctation of the aorta during infancy. J Thorac Cardiovasc Surg 1980;79:603-8. 2. Vosschulte K. Surgical correction of coarctation of the aorta by an "isthmusplastic" operation. Thorax 1961;16:33845. 3. Reul GJ Jr, Kabbani SS, Sandiford FM, Wukasch DC, Cooley DA. Repair of coarctation of the thoracic aorta by patch graft aortoplasty. J Thorac Cardiovasc Surg 1974;68:696-704. 4. Waldhausen JA, Nahrwold DL. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532-3. 5. Geiss D, Williams WG, Lindsay WK, Rowe RD. Upper extremity gangrene: a complication of subclavian artery division. Ann Thorac Surg 1980;30:487-9. 6. Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late
19.
20.
21.
22.
H, Lange P, et al. Assessment of coronary and aortic anastomosis after anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 1985;90:597404. Lansman S, Shapiro AJ, Schiller MS, et al. Extended aortic arch anastomosis for repair of coarctation in infancy. Circulation 1986;74(Suppl1):3741. Hesslein PS, McNamara DG, Morriss MJH, Hallman GL, Cooley DA. Comparison of resection versus patch aortoplasty for repair of coarctation in infants and children. Circulation 1981;64:164-8. Del Nido PJ, Williams WG, Wilson GJ, et al. Synthetic patch angioplasty for repair of coarctation of the aorta: experience with aneurysm formation. Circulation 1986;74(Suppl1):324. Bergdahl LAL, Blackstone EH, Kirklin JW, Pacific0 AD, Bargeron LM Jr. Determinants of early success in repair of aortic coarctation in infants. J Thorac Cardiovasc Surg 1982; 83:736-42. Penkoske PA, Williams WG, Olley PM, et al. Subclavian arterioplasty: repair of coarctation of the aorta in the first year of life. J Thorac Cardiovasc Surg 1984;87894-900. Palatianos GM, Thurer RJ, Kaiser GA. Comparison of operations for coarctation of the aorta in infants. J Cardiovasc Surg 1987;28:128-31. Fenchel G, Steil E, Seybold-Epting W, Seboldt H, Apitz J, Hoffmeister HE. Repair of symptomatic aortic coarctation in the first three months of life: early and late results after resection and end-to-end anastomosis and subclavian flap angioplasty. J Cardiovasc Surg 1988;29:257-63. Cobanoglu A, Teply JF, Grunkemeier GL, Sunderland CO, Starr A. Coarctation of the aorta in patients younger than three months: a critique of the subclavian flap operation. J Thorac Cardiovasc Surg 1985;89:128-35. Mellgren G, Friberg LG, Erikeson BO, Sabel KG, Mellander M. Neonatal surgery for coarctations of the aorta: the Gothenburg experience. Scand J Thorac Cardiovasc Surg 1987;21: 193-7. Ladusans EJ, Campalani G, Parsons JM, et al. Recurrence of aortic coarctation following repair of re-implantation of the subclavian artery. Int J Cardiol 1989;23:321-5.
INVITED COMMENTARY It is now almost half a century since Crafoord first repaired a coarctation of the aorta i n a child by resecting the n a r r o w segment and performing an end-to-end anastomosis. Since then many operations have been devised
with n u m e r o u s publications extolling t h e virtues of a given operation. This w o u l d suggest that, perhaps, no operation really solves the problem and t h a t we m u s t continue t o search for the ideal repair of coarctation of the
