Recurrent Aortic Arch Obstruction Research Articles

The anatomic repair of recurrent aortic arch obstruction in children and adolescents

ObjectiveSurgery for recurrent aortic arch obstruction is highly challenging and publications are rare. The aim of this retrospective, single-center study was to evaluate mortality, complications, and reintervention rate after an anatomic repair. MethodsBetween 1999 and 2022, in total 946 operations on the aortic arch were performed at the Children's Heart Center Linz. In 39 cases, the indication was a recurrent or residual aortic arch obstruction or coarctation in a patient aged 18 years or younger. This is our study cohort. The aorta was reconstructed by a direct anastomosis/autograft in 20 patients, patch in 17 patients, and interposition graft in 2 adolescents. In 32 procedures, cardiopulmonary bypass with whole body perfusion was employed, in 4, antegrade cerebral perfusion was employed, in 2, a left heart bypass was employed, and in 1 no cardiopulmonary bypass was used. ResultsMedian (Q1, Q3) age at operation was 253 days (100, 2198 days), weight 7.5 kg (4.5, 17.8 kg). Median cardiopulmonary bypass time was 177 minutes (115, 219 minutes), crossclamp time 73 minutes (49, 102 minutes). Three infants died during the hospital stay: 1 with Williams syndrome, 1 with hypoplastic left heart syndrome, and 1 with heterotaxia. There was no death due to an arch complication. The main complications were 1 neurologic injury after postoperative resuscitation (Williams syndrome) and 1 permanent recurrent laryngeal nerve paralysis. During the follow-up period of median 8.1 years (2.6, 12 years) 1 re-reintervention on the aortic arch was necessary. ConclusionsSophisticated reoperations on the aortic arch could be performed safely. In children, the growth potential of all segments of the aorta could be sustainably preserved by avoiding interposition or extra-anatomic bypass grafts.

Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates

BackgroundThe incidence of reintervention for aortic arch obstruction is 5% to 14% after coarctation or hypoplastic aortic arch repair and 25% after the Norwood procedure. Institutional practice review indicated higher than reported reintervention rates. Our aim was to assess the impact of an interdigitating reconstruction technique on reintervention rates for recurrent aortic arch obstruction. MethodsChildren (<18 years) were included if they had undergone aortic arch reconstruction by sternotomy or the Norwood procedure. Three surgeons participated in the intervention with staggered rollout dates between June 2017 and January 2019, with the study ending December 2020 and review for reinterventions ending February 2022. Preintervention cohorts represented patients who underwent aortic arch reconstructions with patch augmentation, and postintervention cohorts represented patients who underwent an interdigitating reconstruction technique. Reinterventions by cardiac catheterization or operation were measured within 1 year of initial operation. Wilcoxon rank sum and χ2 tests were used to compare preintervention and postintervention cohorts. ResultsOverall, 237 patients were included for participation in this study, with 84 patients in the preintervention cohort and 153 in the postintervention cohort. Patients undergoing the Norwood procedure represented 30% (n = 25) of the retrospective cohort and 35% (n = 53) of the intervention cohort. Overall reinterventions were significantly decreased after the study intervention from 31% (n = 26/84) to 13% (n = 20/153; P < .001). Reintervention rates were decreased for each intervention cohort: aortic arch hypoplasia (24% [n = 14/59] vs 10% [n = 10/100]; P = .019) and Norwood procedure (48% [n = 12/25] vs 19% [n = 10/53]; P = .008). ConclusionsThe interdigitating reconstruction technique for obstructive aortic arch lesions was successfully implemented and is associated with a decrease in reinterventions.

Hybrid Approach for Correction of Recurrent Aortic Arch Obstruction After Repair of Interrupted Aortic Arch—A Case Report

Recurrent aortic arch obstruction (RAAO) following repair of interrupted aortic arch (IAA) occurs in up to 50% of patients. Treatment options are surgical correction or percutaneous catheter intervention. Balloon angioplasty has become more popular over the last 3 ​decades, but current studies suggest that it may be less effective than surgical treatment.1,2

Experience of stent implantation for recurrent aortic arch obstruction following Norwood or Damus–Kaye–Stansel operation over the last decade

Recurrent aortic arch obstruction following the Norwood procedure is recognised as an important complication. Balloon arch angioplasty is associated with a high recoarctation rate. We sought to evaluate the prevalence and outcome of stent implantation for recoarctation in children following Norwood or Damus-Kaye-Stansel procedure over the past decade at a single national cardiology centre. Of 114 children who underwent Norwood procedure or Damus-Kaye-Stansel procedure between January 2003 and June 2013, 80 patients survived. Of these 15 children underwent stent implantation for recoarctation. Six of these patients had previous balloon angioplasty. The median age at stent implantation was 4.4 months (range 2-82 months). The median peak aortic arch gradient at catheterisation decreased from 26mmHg (range 10-70mmHg) to 2mmHg (range 0-20mmHg). The median luminal diameter increased from 4.7 mm (range 3.2-7.9 mm) to 8.6 mm (range 6.2-10.9 mm). The median coarctation index increased by 0.49 (range = 0.24-0.64). A Valeo stent was employed in 11 children, a Palmaz Genesis stent in 2 patients, a MultiLink stent in 1 child, and a Jomed covered stent in 1 child. Two factors were associated with the need for stent placement: previous arch angioplasty (p valve < 0.001, χ-square 11.5) and borderline left ventricle (p = 0.04, χ-square = 4.1). Stent migration occurred in one child. There were two deaths related to poor right ventricular systolic function and severe tricuspid regurgitation. Six patients underwent redilation of the stent with no complications. The prevalence of recurrent aortic arch obstruction following Norwood/Damus-Kaye-Stansel procedure was 18%. Stent implantation is safe and reliably eliminates the aortic obstruction. Redilation can be successfully achieved to accommodate somatic growth or development of stent recoarctation.

Coarctation Index Predicts Recurrent Aortic Arch Obstruction Following Surgical Repair of Coarctation of the Aorta in Infants

Recurrent aortic arch obstruction (RAAO) remains a major cause of morbidity following surgical neonatal repair of coarctation of the aorta (CoA). Elucidating predictors of RAAO can identify high-risk patients and guide postoperative management. The Coarctation index (CoA-I), defined as the ratio of the diameter of the narrowest aortic arch segment to the diameter of the descending aorta, has been used to help diagnose RAAO in neonates following the Norwood Procedure. We sought to assess the predictive value of the CoA-I on RAAO after CoA repair in infants with biventricular circulation. Clinical, surgical, and echocardiographic data of infants with biventricular circulation following neonatal CoA repair between 2010 and 2014 were evaluated. RAAO was defined using a composite quantitative outcome variable: a blood pressure gradient >20, a peak aortic arch velocity >3.5m/s by echocardiogram, or a catheter-measured peak-to-peak gradient >20 within 2years of surgery. Univariate and multivariate logistic regression analyses were used. Of the 68 subjects included in the analysis, 15 (22%) met criteria for RAAO. In the multivariate model, only CoA-I (OR 35.89, 95% CI 6.08-211.7, p<0.0001) and use of patch material (OR 9.26, 95% CI 1.57-54.66, p=0.014) were associated with increased risk of RAAO. The odds of developing RAAO was higher in patients with a CoA-I less than 0.7 (OR 33.8, 95% CI 5.7-199.5, p<0.001). Postoperative CoA-I may be used to predict RAAO in patients with biventricular circulation after repair of CoA. Patients with a CoA-I less than 0.7 or patch aortoplasty warrant close follow-up.

Aortic Arch Advancement and Ascending Sliding Arch Aortoplasty for Repair of Complex Primary and Recurrent Aortic Arch Obstruction.

The optimal treatment of patients with complex coarctation of the aorta and hypoplastic aortic arch is controversial. Children undergoing repair of obstructive arch lesions are at lifelong risk of recurrence. Multiple techniques have been described to address complex primary and recurrent coarctation. Our approach at Texas Children's Hospital (Houston, TX) has been to address these lesions in an anatomic fashion via median sternotomy, under cardiopulmonary bypass using the techniques of aortic arch advancement and ascending sliding arch aortoplasty. Anatomic repair of complex primary or recurrent aortic obstruction is safe and produces a favorable repair with a low rate of recurrence. Both operations restore normal arch contour using native aortic tissue. The decision of which particular surgical strategy to use depends on the patient's age, anatomy, and the elasticity of the tissue.

Aortopulmonary Window and the Interrupted Aortic Arch: Midterm Results With Use of the Single-Patch Technique

An aortopulmonary window (APW) associated with an interrupted aortic arch (IAA) can be associated with significant rates of perioperative mortality and recurrent arch obstruction. We assessed the outcomes associated with the use of a single pericardial patch technique for primary repair. Between 2002 and 2011, 9 neonates and 2 infants with APW and IAA underwent single-stage repair, under a hypothermic (28°C) continuous cardiopulmonary bypass with antegrade selective cerebral perfusion. A single autologous pericardial patch (glutaraldehyde-fixed) was used both to augment the IAA end-to-side anastomosis and to close the APW by use of the "sandwich" technique. The IAA was type A in 6 patients and type B in 5 patients. The APW morphology was type I in 6 patients, type II in 4 patients, and type III in 1 patient. The median age and weight at operation were 11 days (range, 6 to 180 days) and 2.6 kg (range, 2.2 to 6.5 kg), respectively. The mean cardiopulmonary bypass and aortic cross-clamp times were 108.6 ± 27.5 minutes and 49.3 ± 13.4 minutes, respectively. One patient required additional closure of a ventricular septal defect. Delayed sternal closure was performed in 8 patients. The mean follow-up time was 6 ± 3 years. There were no early and no late deaths. Postoperative morbidity consisted of one postoperative stroke with no late sequelae. There were no reoperations. The last follow-up visits confirmed the absence of recurrent aortic arch obstruction and pulmonary artery branch stenosis in all patients. Primary anatomic repair of APW associated with IAA can be safely performed. The efficiency of the single-patch technique was confirmed by the restoration of normal functional anatomy of the great arteries and aortic arch during follow-up.

Contemporary Results of Surgical Repair of Recurrent Aortic Arch Obstruction

There is a paucity of data on the current outcomes of surgical intervention for recurrent aortic arch obstruction (RAAO) after initial aortic arch repair in children. The goal of this study is to report the long-term results in these patients. All patients undergoing surgical intervention for RAAO at Texas Children's Hospital from 1995 to 2012 were included. The cohort was divided into four groups based on initial procedure: (1) simple coarctation repair, (2) Norwood procedure, (3) complex congenital heart disease, and (4) interrupted aortic arch. A total of 48 patients age 9 months (range, 22 days to 36 years) underwent 49 procedures for RAAO. All patients had an anatomic repair consisting of either patch aortoplasty (n=27, 55%), aortic arch advancement (n=8, 16%), sliding arch aortoplasty (n=6, 12%), placement of an interposition graft (n=2, 17%), reconstruction with donor allograft (n=4, 8%), extended end-to-end anastomosis (n=1, 2%), or redo Norwood-type reconstruction (n=1, 2%). Most procedures (n=46, 94%) were performed through a median sternotomy using cardiopulmonary bypass. At a median follow-up of 6.1 years (range, 9 days to 17 years), only 2 patients required surgical or catheter-based intervention for RAAO. Hypertension was present in 10% of patients at last follow-up. There were no neurologic or renal complications. There was 1 perioperative death after an aortic arch advancement in group 1. Four other patients have died during follow-up, none of the deaths related to RAAO. Anatomic repair of RAAO is a safe procedure associated with low morbidity and mortality, and low long-term reintervention rates.

Aortic arch reconstruction in newborns with an autologous pericardial patch: contemporary results

The incidence of recurrent aortic arch obstruction after Norwood procedure and other types of aortic arch reconstruction in newborns remains high. Biological and synthetic materials are used to enlarge the aorta. We report our experience using autologous pericardium to reconstruct the aortic arch in patients with hypoplastic left heart syndrome, aortic arch interruption and hypoplastic aortic arch. A retrospective analysis of 39 consecutively operated patients evaluated after an initial Norwood and other types aortic arch repair was performed. The presence of recurrent arch obstruction (mean gradient ≥ 20 mmHg) and its management were noted. The mean weight of our patients was 3.2 ± 0.7 kg. The mean age at primary surgical correction was 7.4 ± 6.8 (range 1-35 days). All patients were discharged without a significant residual gradient at the aortic arch except 4 who had a peak gradient of ≥ 30 mmHg. The overall incidence of recurrent arch obstruction was 28.2% (11 patients). Four (12.1%) patients had a distal obstruction, 1 (3%) had proximal obstruction and 1 had a mid-transverse arch obstruction. All patients underwent aortic arch reintervention consisting of balloon dilatation, and only after unsuccessful dilatation, 3 underwent surgical patch aortoplasties. The use of autologous pericardium in aortic arch reconstruction procedure is effective and associated with an acceptable incidence of recurrent arch obstruction. Its availability and characteristics make it an attractive alternative to other materials.

Fifteen-year single-center experience with the Norwood operation for complex lesions with single-ventricle physiology compared with hypoplastic left heart syndrome

The Norwood procedure, the first surgical step of staged palliation for hypoplastic left heart syndrome, is also applied for other complex single-ventricle lesions with systemic outflow tract obstruction or aortic arch hypoplasia. We reviewed our 15-year institutional experience with the Norwood procedure for patients with and without hypoplastic left heart syndrome. A total of 41 patients without hypoplastic left heart syndrome and 212 patients with hypoplastic left heart syndrome who underwent a Norwood procedure between January 1996 and December 2010 were enrolled. Full medical records were reviewed to assess the determinants of outcome. Early failure (death or cardiac transplantation) was 7% in patients without hypoplastic left heart syndrome and 13% in patients with hypoplastic left heart syndrome (P = .29). Frequency of postoperative complications, duration of postoperative ventilation, and length of vasoactive drug treatment were not different between groups. Transplant-free survival until the second operative step trended to be higher for patients without hypoplastic left heart syndrome (92% vs 80%, P = .067). Recurrent aortic arch obstruction was more common in patients without hypoplastic left heart syndrome (15/39 vs 32/171, P = .008), but there were 4 patients with stenosis of the proximal aortic arch. In subsequent procedures, 31 patients without hypoplastic left heart syndrome underwent superior cavopulmonary anastomosis and 5 biventricular repair. Overall transplant-free survival was not different between groups (P = .119) but trended to be higher in patients with a systemic or substantial left ventricle remnant contributing to cardiac output (P = .082). Early and long-term survivals and postoperative complications were similar between patients with and without hypoplastic left heart syndrome undergoing a Norwood operation. Recurrent aortic arch obstruction was common in both groups but more prevalent in patients without hypoplastic left heart syndrome.

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Anatomic Repair of Recurrent Aortic Arch Obstruction

Children undergoing repair of aortic coarctation are at lifelong risk of developing recurrent aortic obstruction. Several surgical techniques have been described to address this challenging problem. Some centers have used extraanatomic aortic bypass techniques to avoid dissection on the previously operated field. We have favored a technique that relies on anatomic reconstruction. Although a repeat end-to-

Coarctectomy combined with an interdigitating arch reconstruction results in a lower incidence of recurrent arch obstruction after the Norwood procedure than coarctectomy alone

Recurrent aortic arch obstruction after the Norwood procedure continues to be a source of morbidity. We sought to determine if a modified interdigitating technique for aortic arch reconstruction during the Norwood procedure decreased recurrent arch obstruction. A total of 142 consecutive infants undergoing the Norwood procedure were divided into groups according to surgical technique: Group 1 (n = 79, January 1999 to May 2003) underwent arch reconstruction with complete coarctectomy followed by anastomosis of the descending aorta to the transverse arch. Group 2 (n = 63, June 2003 to September 2006) underwent complete coarctectomy plus a modified interdigitating technique. Catheterization before stage 2 palliation was reviewed for hemodynamics and angiographic arch dimensions, and a coarctation index was calculated. Reintervention for recurrent coarctation occurred in 28% (22/79) of group 1 patients compared with 2% (1/63) of group 2 patients (P = .001). Aortic pressures, gradients, dimensions, and coarctation index were consistently more favorable for group 2. Coarctectomy plus an interdigitating arch anastomosis was superior to coarctectomy alone and resulted in a dramatically decreased incidence of recurrent arch obstruction.

Pathology of the Aortic Arch in Hypoplastic Left Heart Syndrome: Surgical Implications

Aortic arch reconstruction plays an important role in the success of the Norwood procedure (NP) for hypoplastic left heart syndrome (HLHS). This study investigated the cardiac specimens to determine the etiology of distal aortic arch obstruction after the NP for HLHS and to locate coarctation of the aorta in HLHS untreated by surgery. This study examined 17 cardiac specimens: 9 that had NP and 8 not treated by surgery. The findings after NP showed frequent failure to resect the coarctation segment completely and failure to extend the augmentation patch into the descending aorta. Five (62.5%) of the eight hearts not treated by surgery had significant periductal coarctation of the aorta. After NP for nine patients, three (33%) had residual coarctation of the aorta. To minimize the risk of recurrent or persistent aortic arch obstruction after NP and to improve the long- and short-term outcome, the ductal tissue and the coarctation segment encircling the aortic lumen should be resected. The distal wall incision should be extended at least 5 mm beyond the distal aspect of the ductal tissue. These steps could avoid major aortic arch obstruction, promote growth of the native aortic tissue, and avoid ventricular dysfunction.

Endovascular stent placement is an acceptable alternative to reoperation in selected infants with residual or recurrent aortic arch obstruction

To describe endovascular stent placement in infants as a technically feasible option in circumstances where surgery is considered less favorable. Endovascular stent placement has become established as a first line therapy for native coarctation of the aorta or recoarctation in older children where stents capable of expansion to adult size can be placed safely. Surgery remains the therapy of choice in infants and young children. The management of aortic arch obstruction in infants is, however, frequently complicated by complex anatomy or clinical condition that may make surgery or further surgery an unattractive option. There is little reported data and the implications thereof of transcatheter stent placement in aortic arch obstruction in infants. Between August 2004 and November 2009, 11 patients had aortic arch obstruction treated with endovascular stent placement. The median age and weight at first stent placement was 46 days (range 3-399 days) and 4 kg (range 1.4-8 kg), respectively. In 10 patients, surgical intervention preceded transcatheter stent placement. Four had complex aortic arch obstruction and seven had recoarctation. Reduction in peak systolic gradient to <10 mm Hg was achieved in seven of 10 patients with an improvement in aortic artery diameter to >90% of adjacent aorta in all. The diameter of the arch obstruction increased from a median of 1.60 to 4.90 mm (P = 0.001) and the peak systolic gradient from 45 mm Hg to 8 mm Hg (P < 0.0001). Adverse events occurred in two patients one who required further surgical revision and a second who required placement of a second stent. The median follow up was 3.60 years (range 0.4-5.5 years) with two patients having died at 1.34 and 1.42 years poststent placement. Of the nine patients alive, six have since undergone further angioplasty at a median time interval of 0.77 years (range 0.17-2.76 years). Long-term complications occurred in none. Endovascular stent placement in infants is technically feasible with good results achievable even in small babies. It should be considered as a therapeutic option in complex cases when surgical alternatives are less favorable.

Anterograde Stent Implantation for Treatment of Recurrent Coarctation After Norwood Operation

Although balloon angioplasty (BA) has become the standard therapy for recurrent aortic arch obstruction, pressure gradient relief is often not complete, with a high incidence of restenosis after BA. We report our experience with anterograde stent implantation for treatment of recurrent arch obstruction in patients with hypoplastic left heart syndrome after Norwood operation. Between March 2003 and January 2006, seven patients with the Norwood procedure required BA. The average weight was 6.3 kg (range, 4.4-9.8 kg). Four patients had undergone prior BA. For the purpose of relieving aortic arch obstruction, we used five Palmaz Genesis (PG) XD stents, and for palliative purposes we used one PG 124P stent and one Jostent, 6-12 mm. The average time after Norwood stage I was 177 days (range, 56-365 days). In six of seven patients the procedure was performed antegradely from the femoral vein. In all patients the procedure was effective. The peak systolic gradient fell from 29 mm Hg (range, 5-70 mm Hg) to 3 mm Hg (range, 0-10 mm Hg). There were no complications. No aneurysm, stent dislocation, or severe bleeding was observed. In two of seven patients three growth-related redilatations were performed. We conclude that implantation of stents at the site of recurrent coarctation after Norwood operation shows excellent gradient relief. To reduce the risk of vascular complications due to arterial access in this small group of patients, the procedure can be done safely anterogradely.

Experience With Bovine Pericardium for the Reconstruction of the Aortic Arch in Patients Undergoing a Norwood Procedure

The incidence of recurrent aortic arch obstruction after the Norwood procedure is between 0% and 36%. Allograft material is frequently used to enlarge the aorta; its use has been associated with the development of significant allosensitization. We report our experience using bovine pericardium for the reconstruction of the aortic arch in patients undergoing a Norwood procedure. A retrospective analysis of 33 consecutive patients evaluated for a second-stage procedure after an initial Norwood repair was performed. All patients underwent a cardiac catheterization. The presence of recurrent arch obstruction (gradient > 10 mm Hg) and its management were noted. Three consecutive patients were tested for anti-HLA antibodies at the time of their Fontan procedure. The mean age at the time of the cardiac catheterization was 4.12 months (range, 2 to 7 months). The incidence of recurrent arch obstruction was 18.2% (6 patients). Four patients (12.1%) had distal obstruction, 1 patient (3%) had proximal obstruction, and 1 patient (3%) had mid-transverse arch obstruction. Five of the 6 patients underwent aortic arch reintervention consisting of four balloon dilatations and two surgical patch aortoplasties. Thirty-one patients advanced to a second-stage procedure, including 30 bidirectional Glenn anastomoses, and 1 Rastelli repair. No significant allosensitization was present in the patients tested. The use of bovine pericardium in the Norwood procedure is associated with an acceptable incidence of recurrent arch obstruction. Its availability, lower cost, and possible immunologic advantages make it an attractive alternative to allograft material.

Coarctectomy reduces neoaortic arch obstruction in hypoplastic left heart syndrome

Neoaortic arch obstruction after stage I palliation is an important risk factor affecting interstage mortality in patients with hypoplastic left heart syndrome, with no accepted standard surgical approach. We sought to determine the efficacy of different techniques for aortic arch reconstruction to reduce the incidence of postoperative neoaortic arch obstruction. From January 2000 through June 2005, 210 patients underwent stage I palliation. To enlarge the aortic arch, 12 (6%) patients had a direct connection, 115 (55%) patients had an aortic homograft, 53 (25%) patients had a pulmonary homograft patch, and 30 (14%) patients had autologous pericardium. Independent of the technique for aortic enlargement, 55 (26%) children had coarctectomy. Eighty patients had a significant arch gradient, as determined by means of echocardiography, and of these, 50 required balloon angioplasty, surgical arch augmentation, or both. Preoperative aortic coarctation was consistently linked to neoaortic arch obstruction (P = .032). Patients having aortic arch enlargement by means of direct connection or with autologous pericardium were less likely to have neoaortic arch obstruction (P = .049). Coarctectomy resulted in a lower incidence of neoaortic arch obstruction, as determined by means of echocardiography (P = .015), or need for reintervention (P = .01). Patients with hypoplastic left heart syndrome undergoing aortic arch enlargement with autologous tissue are less likely to require intervention for neoaortic arch obstruction compared with those having homograft patch reconstruction. Excision of all ductal tissue by means of coarctectomy reduces the risk of recurrent aortic arch obstruction. An aggressive approach to reconstruction of the arch and the use of autologous tissue at the time of stage I palliation is advocated.

Anatomic reconstruction for recurrent aortic obstruction in infants and children

Background Patients undergoing operative repair of aortic obstruction are at a lifelong risk of recurrent obstruction, and there is controversy regarding the optimal surgical technique. We have used an alternative strategy for recurrent aortic obstruction, typically involving anatomic reconstruction by means of a median sternotomy, and describe our techniques and results. Methods Twenty-one patients presented with recurrent aortic arch obstruction. Mean age and weight were 7.8 ± 5.4 years (range, 0.21 to 15.2 years) and 30.6 ± 21.8 kg (range, 3.6 to 90 kg), respectively. Recurrence involved the aortic arch to some degree in each case, as the mean preoperative transverse aortic arch z score was −2.9 ± 1.6 (range, −7.0 to 0.1). Thoracotomy was possible in 2 patients, using re-resection with end-to-end anastomosis (n = 1) and patch aortoplasty (n = 1). The remaining 19 patients required median sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest for complete relief of obstruction by aortic arch advancement (n = 10), patch aortoplasty (n = 8), or interposition grafting (n = 1). Results There was 1 hospital death. Invasive blood pressure monitoring revealed no residual arm-to-leg gradient in 19 patients and a 20-mm Hg gradient in 2 patients. There have been no late deaths. No patients have undergone subsequent aortic intervention, and all are asymptomatic up to 85 months postoperatively. Two patients are currently followed with a 10-mm Hg arm-to-leg blood pressure gradient. Conclusions Anatomic reconstruction for recurrent aortic obstruction can be safely accomplished in the majority of patients. We favor median sternotomy because of the ability of establishing cardiopulmonary bypass, the facility of anatomic reconstruction techniques, and the ability to repair concomitant cardiovascular lesions.

Anatomic reconstruction of recurrent aortic arch obstruction in children.

Anatomical reconstruction of the aortic arch following aortic arch surgery is challenging. The placement of an extra-anatomical aortic bypass has been proposed for these difficult cases. This approach is not ideal in children due to possible long-term complications. This study presents the results of our policy to reconstruct the aortic arch in recurrent obstruction in children, which are not amenable to balloon dilatation. Seven children with a median age of 8 years (range 1 month-15 years) were operated for aortic arch obstruction following correction of an aortic coarctation. Six children presented another intra-cardial lesion (2 subaortic membranes; 2 VSDs, 1 ostium stenosis of the left main coronary artery, and 1 mitral valve insufficiency). The surgical approach involved a sternotomy, cardiopulmonary support using two arterial inflow cannulas (one above and one below the aortic arch), and moderate hypothermia. Enlargement of the aortic arch was performed by a sliding plasty in four patients and by a patch plasty in three patients. Associated cardiac defects were corrected as well. It was technically possible to perform the planned operation in all patients. All patients survived and none presented significant postoperative complications. There were no residual gradients in six patients and a gradient of 10 mmHg in one patient postoperatively. One patient showed transient recurrent nerve palsy which recovered within 6 weeks. Follow-up echocardiographic and MRI studies revealed a normal appearing aortic arch with laminar flow. Although more demanding, an anatomical reconstruction of the aortic arch can be performed in infants and children with recurrent obstruction of the aortic arch with excellent initial results. This approach may prove superior to an extra-anatomic bypass in the long-term.