Invited Commentary

Abstract

The group from the Royal Children’s Hospital, Melbourne has reported an extensive series of end-to-side repair for aortic arch lesions, coarctation, and aortic arch interruption [1Lee M.G.Y. Brink J. Galati J.C. et al.End-to-side repair for aortic arch lesions offers excellent chances to reach adulthood without reoperation.Ann Thorac Surg. 2014; 98: 1405-1411Abstract Full Text Full Text PDF PubMed Google Scholar]. Two aspects of this report are notable: (1) the long follow-up of these patients and (2) the uniform technique applied to the arch repair. The 18-year survival was 93%, with a freedom from arch reoperation of 87%. These results are exemplary and provide a benchmark for future reports using differing methods of arch repair. The aortic arch was repaired by direct anastomosis in all cases without need for patch supplementation, which I think is remarkable when one considers how small the ascending aorta can be in cases of interruption. There must presumably be great potential for growth of the ascending aorta in this group of patients. However, it is also commented on in Lee and colleagues' article that extensive repair of the aortic arch is advocated because there is evidence that the aortic arch hypoplasia existing in the infant may well persist into adult life, predisposing to aortic arch problems, the need for reintervention, and systemic hypertension. Regarding the arch repair technique itself, the authors emphasize the need for extensive mobilization of the descending thoracic aorta and interruption of the first 3 intercostal arteries. The authors note the limitations for use of the end-to-side repair in the case of complex root reconstructions, for instance in the Damus-Kaye-Stansel type of repair, which may risk bronchial obstruction. As far as I am aware, this is one of the longest follow-ups reported in a group of patients with aortic arch pathologic processes. It is evident from the technical aspects described in the article that meticulous technique with excision of all duct tissue will allow excellent early outcomes and long-term survival in the majority of cases, even when intracardiac repairs are required. End-to-Side Repair for Aortic Arch Lesions Offers Excellent Chances to Reach Adulthood Without ReoperationThe Annals of Thoracic SurgeryVol. 98Issue 4PreviewThe purpose of this study was to determine the rate of reinterventions from birth to adulthood after end-to-side anastomosis technique for interrupted and hypoplastic aortic arches. Multicenter data have shown that more than half of patients require arch reintervention in the 2 decades after repair. Full-Text PDF