Subclavian Flap Research Articles

Reply to Troise et al.: Subclavian flap aortoplasty in neonates and infants

Reply to Troise et al.: Subclavian flap aortoplasty in neonates and infants

Surgical treatment of coarctation in small infants: our experience

We read with great interest the article by Barreiro et al. [1] regarding the current role of subclavian flap aortoplasty (SFA) in the surgical treatment of coarctation in infancy. We are in complete agreement with the authors that the SFA still has a role in isolated isthmic coarctation repair, in infancy as well as in the most difficult subgroups of patients operated in neonatal age. In fact, the technique itself allows excellent aortic continuity with naturally harmonious restoration of the aortic arch—isthmus tract. These goals are not foreseen either with patch aortoplasty or with endto-end (ETE) anastomosis, both of which, respectively, distort and eliminate the stenotic thoracic aorta. If the hypoplasia of the aortic arch is mild-to-nil, the physiological antegrade flow through the arch and the absence of gradient at the end of the procedure will guarantee adequate longterm repair, in most cases. In our institute, 178 patients presenting with neonatal coarctation were operated. In the search for the (perhaps utopic) ideal surgical management, we have changed our surgical strategy over the years in our institute. In the earlyto-mid phase of our activity we proposed a patch aortoplasty for all neonates that has the advantage of always relieving the gradient at the level of the isthmus by means of a technique which is both timeand hemorrhage-controlled. The incidence of aneurysm formation in the long term (2/178 in our experience at a follow-up of 10 years, but frequently reported in the literature [2] to longer follow-up) and the high rate of recoarctation (26%) discouraged us from electively employing the patch. After a period of non-randomized surgical strategy of SFA, extended ETE (EETE) anastomosis and ETE anastomosis technique, in our institute we currently adopt the following strategies:

Endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation

Whatever the surgical technique used, false aneurysm formation is one of the long-term complications of repair of aortic coarctation. Conservative management is associated with a 100% rate of rupture. The conventional surgical approach is complex and associated with high morbidity and mortality rates. We report our experience of endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation. Between October 2005 and 2006, stent-grafting of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation was performed in four patients. Median age was 31.5 years (range: 24-38). Two patients had undergone two previous interventions. The last previous surgery consisted of graft interposition (N=2), subclavian flap aortoplasty (N=1) and aorto-aortic bypass (N=1). Median size of the pseudo-aneurysm was 31.5mm (range: 20-58). Mean time between the last surgery and endovascular treatment was 24 years (range: 3-32). One patient was treated emergently because of hemoptysis in relation with an aorto-bronchial fistula, the three other patients were treated electively. A transfemoral approach was used in all patients. The Zenith TX2 (Cook) thoracic stent-graft was used in all the patients, one patient underwent previous dilatation at the coarctation level. When present, the ostium of the left subclavian artery was always covered (N=3). No major complication occurred during the procedure and no patient died during the follow-up. One patient presented a type II endoleak which spontaneously healed during the first month. Another patient with his left subclavian artery covered presented claudication of the left arm requiring a carotid-subclavian bypass. After a median follow-up of 7.5 months (range: 1-12.9), the patients were asymptomatic and CT scans demonstrated complete exclusion of all treated postcoarctation aneurysms without recoarctation and without any stent-graft-related complication. The endovascular management of pseudo-aneurysms after previous surgical repair of congenital aortic coarctation is feasible. This approach was safe and effective. Long-term clinic and imaging follow-up is mandatory.

Subclavian flap aortoplasty: still a safe, reproducible, and effective treatment for infant coarctation

Subclavian flap repair of infant coarctation has been criticized and in many centers abandoned in favor of resection with end-to-end anastomosis. The goal of this study was to examine intermediate and long-term results of infant subclavian flap aortoplasty, which has been the preferred technique at our institution over the last two decades. Our patient database identified all infants (age<1 year) who underwent repair of isthmic coarctation via thoracotomy between January 1984 and December 2004. Procedure details and late results were collected by retrospective review of hospital and clinic data. Follow-up was 95.8% complete at a mean of 6.7 years. Between January 1984 and December 2004, 119 infants underwent isolated subclavian flap repair of coarctation. Mean age and weight at operation were 35+/-52 days (range 1-269 days) and 3.5+/-1.3kg (range 0.7-9.3kg), respectively. Concomitant pulmonary artery banding was performed in 22% (26/119). In-hospital mortality was 4% (5/119) and cumulative late mortality was 6% (7/114) of patients with long-term follow-up. Actuarial survival at 1, 5, and 10 years was 91, 85, and 85%, respectively. Overall re-intervention rate for re-stenosis was 11% (12/114); 10 patients (9%) underwent balloon angioplasty while 3 patients (3%) required operative revision. All re-stenoses occurred in the descending aorta, and all occurred in patients who had undergone neonatal repair. At late follow-up, there were no significant neurologic events (left recurrent laryngeal nerve injury, stellate ganglion dysfunction, or paraplegia), no clinically significant ischemic arm complications, and no flap aneurysms. Subclavian flap aortoplasty remains our procedure of choice for isthmic coarctation, as it is a simple, technically straightforward technique with a low incidence of re-stenosis and serious early and late morbidity. Furthermore, subclavian flap re-stenoses are easily treated with percutaneous intervention and seldom require surgical re-intervention via thoracotomy.

Truncus Arteriosus With Interrupted Aortic Arch: Successful Repair Using Modified Cardiopulmonary Bypass and Surgical Techniques

A neonate with truncus arteriosus (type 1) and interrupted aortic arch (type A) associated with an excessively large gap between interrupted aortic segments underwent successful reconstruction of the aortic arch with a partial subclavian flap aortoplasty plus bovine jugular patch (Contegra 200, Medtronic, Inc, Minneapolis, MN) using continuous selective low-flow cardiopulmonary bypass without circulatory arrest. The ventricular septal defect was closed with a Dacron (IMPRA, Inc, Tempe, AZ) patch, and a Contegra prosthesis was used to re-establish right ventricle to pulmonary artery continuity. At an 18-month follow-up, the patient was free of symptoms with normal development. Echocardiography revealed a widely patent aortic arch and an unobstructed right ventricle to pulmonary artery connection.

Repair of Coarctation of the Aorta in Infants Weighing Less Than 2 Kilograms

We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients. Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1). Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair. Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.

Subclavian Flap Repair: Review of 399 Patients at Median Follow-Up of Fourteen Years

Conflicting results have been obtained for the same operation for repair of coarctation of the aorta by different institutes. The purpose of this study was to assess the results of subclavian flap aortoplasty (SFA) alone, performed on 399 patients in a single institute between 1966 and 1995. Data were collected retrospectively from the congenital cardiac surgical database at the institute. The median age at operation was 22 days (3 days-49 months). One hundred thirty-four patients had isolated coarctation while 265 children had complex coarctation. Maximum follow-up was 24 years (median, 14 years). Overall mortality over the whole duration of follow-up was 24.8%. Mortality for isolated coarctation at first intervention was 7.4% (operative mortality, 2.6%) while it was 12.8% for complex coarctation. At second intervention the mortality for isolated coarctation was 5%. For the second, third, and fourth interventions the mortality for complex coarctation was 25%, 25%, and 27%, respectively. The survival for isolated coarctation at 1, 5, 10, and 20 years was 94%, 93.2%, 92.4%, and 88.4%, respectively, while it was 74.6%, 66.3%, 63%, and 61.4%, respectively, for complex coarctation. Of the total patients, 15.3% had interventions for recoarctation. The incidence of recoarctation was 13.6% on those patients operated on in the first month of life, while it was 3.6% in older children. A percentage of 3.3% of patients continue to be hypertensive and require medication. There was a significant difference between the systolic blood pressure and anthropometric measurements between the arms. Despite this none of the patients complained of effect on lifestyle. Despite improved early results the long-term mortality for coarctation remains high. Mortality is higher for complex coarctation as compared with isolated procedures. The incidence of recoarctation after SFA at long term is acceptable and is higher in patients operated on in the first month of life. The overall incidence of hypertension is quite low. Patients remained normotensive when operated upon at the age of 0.9 months. The SFA, no doubt, effects the limb development; however it does not cause limitation in the lifestyle.

Invited commentary

Since its introduction by Waldhausen in 1966, subclavian flap aortoplasty (SFA) has served as an effective operative modality for infant coarctation of the aorta. As with all abnormalities with multiple, possible methods of repair, its place as a primary operation has been determined by anatomy, surgeon’s preference, and follow-up studies.

The influence of different surgical procedures on hypertension after repair of coarctation

We measured resting and exercise haemodynamics, as well as 24-hour ambulatory blood pressure, so as to study the influence on development of hypertension in children after repair of coarctation by either construction of a subclavian flap or end-to-end anastamosis. The patients in both groups were studied a mean time of 13 years after surgery. Thus, we divided 43 children who had undergone surgical repair of coarctation, and who were not on antihypertensive therapy, into a group of 22 patients who had undergone subclavian flap repair, with a mean age of 14 plus or minus 2.6 years, and another group of 21 patients undergoing end-to-end anastomosis, with a mean age of 13.5 plus or minus 3.9 years. We examined blood pressure at rest and during exercise, along with the measurement of cardiac output using impedance cardiography, and during 24-hour ambulatory monitoring. We recorded systolic and diastolic blood pressures, pulse pressure, cardiac output and total peripheral vascular resistance at rest and at peak exercise. During ambulatory monitoring, we measured mean pressures over 24 hours, in daytime and nighttime, 24-hour pulse pressure, and 24-hour mean arterial pressure. Student's t test was used to judge significance, accepting this when p was less than 0.05. The group repaired using the subclavian flap showed significantly disadvantageous differences for diastolic blood pressure at rest, systolic blood pressure at peak exercise and for 24-hour systolic and diastolic blood pressure, 24-hour mean arterial pressure, and daytime and nighttime systolic blood pressure during ambulatory monitoring. Our findings suggest that, after repair using the subclavian flap in comparison to end-to-end anastomosis, patients show a higher incidence of late hypertension, both during exercise and ambulatory monitoring. The data indicate different residual aortic stiffnesses, these being lower after end-to-end anastomosis, which may be due to the greater resection of the abnormal aortic tissue when coarctation is repaired using the latter technique.

Late aneurysm formation with destruction of the left lung after subclavian flap angioplasty for coarctation of aorta

Aneurysm formation after prosthetic patch repair of coarctation of the aorta was a frequent complication that resulted in abandonment of the procedure. Subclavian flap angioplasty (SFA) was popularized in the 1960s, primarily to prevent late recoarctation.1 However, late aneurysm formation after SFA has been reported in at least 6 cases.2

Late thoracic aortic dissecting aneurysm following balloon angioplasty for recoarctation after subclavian flap aortoplasty in childhood?successful surgical repair under circulatory arrest

Balloon angioplasty is universally accepted presently as the primary therapeutic strategy for recoarctation following surgery during infancy and early childhood. This report concerns a 26-year-old lady with cephalobrachial hypertension on beta-blocker who presented with left sided chest pain since 3 months, having undergone surgery for coarctation in early childhood and balloon angioplasty at 17 years of age. Chest X-ray showed prominent aortic knuckle. CT scan chest showed features of residual coarctation with "double-barrelled" upper thoracic aorta of 5cm diameter. Surgery consisted of interposition graft repair of distal arch and upper thoracic aorta under total circulatory arrest through posterolateral thoracotomy leading to excellent recovery.

Reverse Subclavian Flap Repair for Coarctation with Hypoplastic Arch

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

Evolutional aspects of children and adolescents with surgically corrected aortic coarctation: clinical, echocardiographic, and magnetic resonance image analysis of 113 patients

Objective The goals of this study were to determine the prevalence of hypertension and recoarctation in operated children and teenagers and to integrate clinical and imaging technique data. Methods One hundred thirteen infants and children (ages 14 years or less) were retrospectively divided into 3 groups according to the age at operation and the surgical technique: 79 underwent resection with end-to-end anastomosis; 14 had patch enlargement; 13 had subclavian flap aortoplasty; and 7 had other techniques performed. The mean age at operation was 3.95 ± 4.17 years and the mean follow-up period was 4.62 ± 4.90 years. Each patient was clinically examined and Doppler echocardiography was performed in 112 patients. Sixty-six patients underwent magnetic resonance imaging. Diameters of aortic arch were measured at 4 levels; the ratios between each one and descendent aorta diameters were calculated. Qualitative variables and associations were studied by Fisher exact test or chi-squared test. Comparisons of measurements in different groups were performed using variance analysis, with tests of selective contrasts (nonparametric tests). The level of statistical significance was <.05. Results The prevalence of hypertension and recoarctation was 38% and 14%, respectively. No statistical difference was found among the age groups. In 65 patients who underwent magnetic resonance imaging, the transverse aortic arch was hypoplastic in 31 (47%) patients; 41 (63%) had stenosis at the site of anastomosis (ratio < 0.9). Conclusion Hypoplasia of transverse aortic arch was highly prevalent. These data suggest that hypoplastic aortic arch should be corrected concomitantly with coarctation.

Composite aortoplasty for recurrent coarctation after neonatal repair in Williams syndrome

Supravalvar aortic stenosis is the most frequent operation required for Williams syndrome; however, coarctation repair is more common in patients requiring surgery in the first few months of life. We report on a child with Williams syndrome in whom extensive reoperation was required 5 months after neonatal aortic coarctation repair. A composite left subclavian artery flap and allograft patch aortoplasty of the aortic arch and descending aorta was performed through a left thoracotomy using cardiopulmonary bypass and circulatory arrest. Detailed anatomic evaluation of the aortic arch and descending aorta is recommended before initial coarctation repair in neonates with Williams syndrome.

Is surgical intervention still indicated in recurrent aortic arch obstruction?

Background Introduction of balloon dilatation has become the standard treatment for recurrent aortic arch obstruction and has changed the therapeutic approach to patients with this disorder. Objectives Whether all patients with recurrent aortic arch obstruction are candidates for balloon dilatation remains unanswered. In addition, only few reports have tried to compare the results between patients undergoing balloon dilatation or redo operations. Methods Since 1983, 97 patients underwent reintervention for recurrent aortic arch obstruction (42 dilations and 55 reoperations). Eight had immediate unsuccessful dilatation and were shifted to the surgical group (n = 63). The median age at reintervention was 21.7 months (10 days-45 years), and the median delay was 13.6 months (7 days-17 years). Anatomy of the aortic arch oriented the surgical approach to treat arch hypoplasia. It could be performed through a left thoracotomy in 52 patients, with extended end-to-end anastomosis in 34 patients, subclavian flap repair in 9 patients, conduit insertion in 6 patients, and patch enlargement in 3 patients. More recently, an anterior approach with cardiopulmonary bypass without circulatory arrest was applied to enlarge the patch in all the aortic arches. Results There was one early death in the surgical intervention group and 2 late deaths in the dilation group. Major complications and recurrence were higher in the dilated group (4 vs 0, P < .01, and 14 vs 5, P < .0004, respectively). At a mean follow-up of 11.8 ± 4.1 years in the surgical intervention group and 7.5 ± 2.5 years in the dilated group, systemic hypertension was normalized in all but 5 patients in the surgical intervention group and 6 patients in the dilated group. Conclusion Reoperation for recurrent aortic arch obstruction can be performed safely, with low rates of mortality and morbidity. This approach should be considered versus balloon angioplasty, especially in patients older than 4 years and in the presence of aortic arch hypoplasia.

Aberrant right subclavian artery with preductal coarctation of the aorta

A 9-day-old boy diagnosed with an aberrant right subclavian artery, a preductal coarctation, and a ventricular septal defect underwent a subclavian flap coarctectomy. Subsequently, he underwent surgical closure of the ventricular septal defect at the age of 11 months. This case is extremely rare with regard to having an aberrant right subclavian artery originating from the proximal site of a preductal coarctation of the aorta.

Severe pulmonary stenosis and aortopulmonary fistula caused by a dissecting aneurysm in the ascending aorta

Discussion Surgical repair of aortic coarctation has expanded to include resection with end-to-end anastomosis, prosthetic patch aortoplasty, subclavian flap aortoplasty, and aortic resection with graft replacement. Because further aortic growth is not a problem in adult patients, graft replacement or bypass is often used and produces the best results. As the aortic wall in the portion of coarctation was thought to be fragile in our case because of the median necrosis, we used an open proxymal anastomosis technique to avoid possible aortic injury caused by crossclamping. The central cannulation technique is preferred for correction of postductal coarctation of the aorta to secure sufficient cerebral perfusion. In our case, this technique also had the advantage of preventing scattering of debris by the blood jet in an aortic aneurysm to cerebral blood flow. We prefer insertion of a venous cannula into the right atrium through the right femoral vein rather than insertion into the main pulmonary artery, as originally reported by Westaby and colleagues, because we have sometimes found that the wall of the main pulmonary artery is very fragile and thus susceptible to injury. We routinely insert a double-staged venous cannula through the right femoral vein in operations for descending aortic aneurysms and have experienced no technical problems. In conclusion, our “modified” central cannulation technique and open proxymal anastomosis technique seem to be safe. This is an appropriate approach for surgical correction, and we recommend it as the standard approach for the coarctation of the aorta in adults.

Correção cirúrgica da coartação da aorta nos primeiros seis meses de vida

OBJETIVO: Avaliar os resultados imediatos e tardios da correção cirúrgica da coartação da aorta torácica (CoAo) nos primeiros seis meses de vida. CASUÍSTICA E MÉTODOS: Entre janeiro de 1994 e maio de 2001, 89 pacientes foram submetidos à correção de CoAo pelas técnicas de aortoplastia com flap de subclávia (Grupo 1 / n=49), e resseção com anastomose término-terminal (Grupo 2 / n=40). Foram analisadas e comparadas as seguintes variáveis: idade no momento da operação, presença de anomalias intracardíacas, gradiente de pressão pré e pós-operatório, complicações e mortalidade cirúrgicas, bem como sobrevida tardia livre de eventos. RESULTADOS: Houve predomínio do sexo masculino (n=60 - 68%) e a grande maioria dos casos foram operados no primeiro mês de vida, por insuficiência cardíaca (IC) refratária (n=62 - 70%). A CoAo apresentou-se isolada em 23 (26%) pacientes, e associada a defeitos intracardíacos em 66 (74%). O gradiente médio pré e pós-operatório foi, respectivamente, de 42 mmHg e 4,5 mmHg, não havendo diferença entre os grupos. As complicações cirúrgicas mais freqüentes foram hipertensão arterial persistente (n=27), estenose residual (n=5) e sangramento (n=3), e a mortalidade operatória foi de 10,2% (n=9), sendo significativamente maior nos casos com cardiopatias associadas (12% vs. 4% - p<0,05). Não houve diferença na incidência de complicações e mortalidade entre os grupos. A ocorrência de recoartação tardia foi de 16% no grupo 1 e 15% no grupo 2 (p=NS), e a taxa de sobrevida livre de eventos em 60 meses foi de 76% e 81%, respectivamente (p=NS). CONCLUSÕES: A maioria dos casos de CoAo manifesta nos primeiros meses de vida requer correção ainda precocemente, por IC refratária. A mortalidade cirúrgica é significativa naqueles pacientes com defeitos intracardíacos; não houve diferenças na morbi-mortalidade e na incidência de recoartação, entre as técnicas cirúrgicas empregadas.

Coarctation of the Aorta: End-to-End Anastomosis

In the diffuse form of coarctation (A), the extent of hypoplasia of the arch may he quite great, including not only the isthmus, hut also the transverse arch between the left carotid and subclavian and even the proximal arch between the innominate and left carotid arteries. In the discrete form (B), the diameters of the aortic arch and isthmus tend to be normal. The hallmark of the discrete form

Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infants: Is low weight a risk factor?

Background: Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age. Methods: From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction. Results: One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P =.01; ||2 weeks, P =.005), smaller transverse arch (absolute diameter, P ||.001; indexed to weight, P =.03; indexed to ascending aortic diameter, P =.02), and smaller ascending aorta (absolute diameter, P =.02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation. Conclusions: Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.J Thorac Cardiovasc Surg 2001;122:883-90