Reverse Subclavian Flap Repair for Coarctation with Hypoplastic Arch

Abstract

Acriticalneonatalcoarctationcanbedefinedasonethatis sufficiently severe to keep the neonate prostaglandindependent. Perfusion distal to the coarctation must be maintained by ensuring patency of the ductus arteriosus and maintaining elevation of pulmonary vascular resistance by appropriate ventilatory manipulation. 1 One of the complexities of managing the critical neonatal coarctation is that it is often associated with hypoplasia of the isthmus,distalaorticarch,orproximalaorticarch.Itmustbe remembered that these segments of the aorta are normally smallerthantheascendingaortaconsequenttothebranching of the aortic arch. In general, an isthmic diameter that is less than 40% of the ascending aortic diameter is inadequate. Likewise a distal aortic arch diameter that is less than 50% of the ascending aorta, or a proximal aortic arch that is less than 60% of the ascending aorta, is inadequate. It is exceedingly common to find severe hypoplasia of the isthmus so that resectionoftheisthmusoraslideplastyasillustratedhereare almost routinely incorporated into the management of criticalneonatalcoarctation.Distalaorticarchhypoplasiaisaless frequent but still not rare problem. Severe hypoplasia of the aortic arch proximal to the left common carotid artery is a very rare finding. The most common technique for dealing with the hypoplastic distal aortic arch has been to perform an extended end-to-end anastomosis as illustrated in the accompanying article by Tsang. However, an alternative approach that we have found particularly helpful in the neonate is to perform a reverse subclavian flap procedure. Disadvantages of the Left Subclavian Flap Approach