Aortic arch reconstruction with reversed subclavian flap technique and patch augmentation for IAA: Use of pericardium patch increases rate of aortic arch stenosis

Abstract

Purpose: To determine the results of a novel technique for interrupted aortic arch (IAA) repair in regard to survival and freedom from reintervention. With the spatulated subclavian artery a reversed flap is created to form the wall of the posterior aortic arch. Either a patch from autologous pericardium or homograft tissues are used to complete the continuity. Methods: We analyzed medical records of patients undergoing IAA repair using this technique. Results: Between April 2000 and July 2012, 27 patients have undergone IAA repair using the subclavian flap technique. Of these, 2 had an aortopulmonary window, 3 a common arterial trunk, and 3 a transposition of the great arteries. In patients with type B interruption (74%) the left subclavian artery (n = 17) or the right arteria lusoria (n = 3) were used. In type A interruption (26%) only the left subclavian artery was used as flap. Arch repair was completed using fixated autologous pericardium (41%) or a homograft patch (59%). Mean follow-up time was 4.1 ± 2.3 years. No patient was lost at late follow-up. In the early period from 2000 – 2005 (5 pts.) there was one early and one late death. Since 2006 no deaths occurred. Aortic arch stenosis requiring reintervention developed in 8 patients (30%). Four of them could be treated with balloon dilatation, four underwent surgical treatment. The rate of aortic arch stenosis was much lower in patients treated with a homograft patch versus those with a pericardial material (13% versus 55%, p = 0.038). Conclusions: The subclavian flap technique is a promising alternative to either direct anastomosis or prosthesis interposition. As a large part of the arch circumference entails use of patch material, its choice is crucial. Preliminary results raise concern about the use of autologous pericardial patch material.