Left internal thoracic artery patch aortoplasty for repair of coarctation of the aorta

Abstract

Adult patients with long coarctation of the aorta (CoA) may require coarctectomy and prosthetic tube or patch implantation. Potential drawbacks of these techniques, such as risk of infection, thrombosis, neointimal ingrowth, and aneurysm formation, are closely related to the use of prosthetic materials. 1-3 To avoid these specific risks, we developed a technique that includes resection of coarctation and two elements of plastic procedure: end-to-end suturing of the aorta posterior wall and patch closure of the longitudinally incised aorta anterior wall. The material for the patch is autologous left internal thoracic artery (LITA). Technique The approach is by left posterolateral thoracotomy through the fourth intercostal space. The length of the CoA and diameter of LITA are measured (Figure 1, A). If the LITA diameter is big enough, then a segment of this vessel is harvested within the area between the second and third intercostal spaces. The arterial cylinder is opened longitudinally to prepare a patch (Figure 1, B). After harvesting, the patch is preserved in sterile normal saline solution. The prestenotic and poststenotic parts of the isthmus of the aorta, coarctation, ligamentum arteriosum, left subclavian artery, and descending thoracic aorta are dissected. The ligamentum arteriosum is ligated and divided. After reduced heparinization (100 IU/kg intravenously), vascular clamps are placed on the aorta; the coarctation, together with ductal tissue, is then excised between the clamps. To achieve as wide as possible a lumen of the aortic anastomosis, two additional longitudinal incisions (approximately 20 mm each) are made: proximally on the isthmus toward the origin of left subclavian artery and distally on the descending aorta. Then the posterior wall of the anastomosis is constructed with 5-0 monofilament polypropylene continuous suture (Figure 2, A). The anastomosis is completed by suturing the LITA patch to the aorta within its longitudinally incised wall (Figure 2, B). The thoracotomy is closed after insertion of a chest drain.