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Creating an Arc-Shaped Aorta: Use of the Subclavian Artery for Interrupted Aortic Arch Repair
Creating an Arc-Shaped Aorta: Use of the Subclavian Artery for Interrupted Aortic Arch Repair
CONGENITAL HEART
Melchior Burri, MD, Jelena Kasnar-Samprec, MD, PhD, Julie Cleuziou, MD, Christian N€ obauer, MD, Manfred O. Vogt, MD, PhD, R€ udiger Lange, MD, PhD, Christian Schreiber, MD, PhD, and J€ urgen H€ orer, MD, PhD Departments of Cardiovascular Surgery and Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich; and DZHK (German Center for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
Background. With interrupted aortic arch (IAA), a direct anastomosis may produce an angular-shaped aortic arch instead of the normal arc-shaped aorta, when the discontinuity is considerably long. That may lead to aortic stenosis and to compression of the pulmonary artery or the main bronchus. If a tube graft is used, reoperation for graft exchange is inevitable. We demonstrate the results of using the subclavian artery for creating an arc-shaped aorta in IAA repair. Methods. Between February 2006 and October 2012, 23 patients underwent IAA repair using the subclavian artery. The subclavian artery was closed distally, divided, and longitudinally incised from the transected end to the aorta. This flap was used to bridge the gap of the IAA, by forming the posterior wall of a new aortic segment. The arch was completed using glutaraldehyde-fixed autologous pericardium (52%) or homograft (48%).
Results. Median follow-up time was 4.8 years (range, 1.3 to 6.9). There were no early deaths and 1 late death. On postoperative angiographic imaging, the aorta takes an arc-shaped course in all cases. Aortic arch stenosis developed in 7 patients (30%). Four patients were treated interventionally, and 3 surgically. During follow-up, there was no compression of the pulmonary artery or the main bronchus. Conclusions. By using the subclavian artery, an arcshaped aorta can be accomplished without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might be not applicable to bridge a long interruption.
D
The aim of this study was to review our operative experience, and analyze the midterm results regarding mortality and need for reintervention.
irect anastomosis with or without a patch, and interposition of a vascular prosthesis are the most commonly used techniques to repair an interrupted aortic arch (IAA) [1, 2]. The use of a subclavian artery is known for aortic coarctation repair [3, 4]. Recent case reports showed a successful adoption of this technique for IAA repair [5–9]. A subclavian flap is used to bridge the interruption of the aorta on the posterior wall. The neoarch is completed with a patch. We have hypothesized that this technique produces an arc-shaped aorta, leaving more space underneath, and thereby, it might avoid pulmonary artery stenosis or left main bronchial stenosis. In addition, the tension at the site of anastomosis may be lower, reducing the incidence of aortic stenosis [8, 9]. Considering these potential advantages, this modified subclavian flap technique was introduced as the standard technique for IAA repair at the German Heart Center Munich in 2006.
Accepted for publication Sept 23, 2014. Address correspondence to Dr Burri, Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Lazarettstrasse 36, Munich D-80636, Germany; e-mail: burri@dhm. mhn.de.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:648–52) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods Between February 2006 and October 2012, 26 consecutive patients with IAA underwent surgery at the German Heart Center Munich. Three patients did not undergo operation by the subclavian flap technique and were excluded. One patient had type C IAA. A direct anastomosis was performed in this patient. One patient underwent Norwood type anastomosis with direct anastomosis, and in 1 patient, a conduit was placed. In both of the 2 latter patients, the reason for not applying the subclavian flap technique was the presence of an alternate team of surgeons, not the anatomy of the patient. Characteristics of the remaining 23 patients included are shown in Table 1. Median follow-up time was 4.8 years (range, 1.3 to 6.9; mean 4.2). Follow-up was complete. The operation was performed using aortic, pulmonary, and bicaval cannulation. The aortic arch was reconstructed under deep hypothermic circulatory arrest. All 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.053
Ann Thorac Surg 2015;99:648–52
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
Table 1. Patient Characteristics Characteristics
23 11 (47) 3.1 0.6 50 3 11 (6–45) 12 (52) 5 (22) 18 (78) 2 (9) 2 (9) 2 (9) 2 (9) 10 (43) 21 (91) 2 (9)
Values are n (%), unless otherwise indicated.
ductal tissue was removed. In patients with type B interruption, the distal ascending aorta was incised at the left lateral wall. The left subclavian artery was closed distally, divided, and opened longitudinally. This subclavian flap was then turned toward the ascending aorta and anastomosed with the incision to construct the posterior aspect of the neoaortic arch (Fig 1). In patients with type A interruption, the left subclavian artery was turned toward the descending aorta. Either homograft (n ¼ 11) or autologous glutaraldehyde-fixed pericardium (n ¼ 12) was used to complete the anterior wall of the aorta. In 3 patients with type B interruption, a right lusorian artery was used instead of the left subclavian artery. Mean circulatory arrest time was 37 8 minutes. Additional procedures were performed at initial operation because of concomitant cardiac anomalies (Table 2). Descriptive statistics are described as frequencies and percentages for categorical variables. Continuous variables are expressed as mean value and standard deviation, if normally distributed, or as median with range if not normally distributed. Confidence interval (CI) is reported as 95% CI. Probabilities of freedom from death and of freedom from reintervention after the initial operation were calculated using the Kaplan-Meier
method. In calculations for reinterventions, death was stated as censoring. All statistical calculations were performed using the R environment (version 2.13.1; R Foundation, Vienna, Austria). The Review Board approved the study and waived the need for informed consent from the parents owing to lack of any patient identifiers and the retrospective nature of the study. All authors had full access to the data, and take full responsibility for its integrity.
Results There was no early death. One patient with severe subaortic stenosis and hypoplastic ascending aorta died of circulatory and respiratory failure 3 years after the initial operation. He underwent a Ross-Konno operation 4 months after the operation. During follow-up, angiography of the aortic arch was performed in 12 patients. In 5 patients, the indication was hemodynamic evaluation before conduit exchange, Glenn procedure, or ventricular septal defect closure. In 5 patients, the indication was evaluation of an echocardiographically suspected restenosis of the aortic arch. In 2 patients, the indication was cardiopulmonary instability due to low oxygen saturation. By using the subclavian flap technique, an arc-shaped aortic arch was achieved (Fig 2). Estimated freedom from reintervention due to aortic arch stenosis was 78% (95% CI: 63% to 97%) at 1 year, and 68% (95% CI: 51% to 91%) at 5 years (Fig 3). In 5 patients, the stenosis was located at the distal end of the patch enlargement. These patients were successfully treated with percutaneous balloon angioplasty. In 3 patients, the stenosis was located at the proximal end of the patch enlargement. These patients were successfully treated surgically. Freedom from all types of reinterventions was 52% (95% CI: 35% to 77%) at 1 year and 46% (95% CI: 29% to 73%) at 5 years. Table 3 shows all reinterventions performed during follow-up.
Comment Interrupted aortic arch reconstruction with the subclavian artery has been reported in individual cases only. In the present study, an arc-shaped aorta was accomplished by using the subclavian artery in 23 patients. The procedure Fig 1. Reconstruction of aortic arch with left subclavian artery. (A) The left subclavian artery is divided and longitudinally incised. (B) The subclavian artery is based as the posterior wall of the aortic arch before completion with patch.
CONGENITAL HEART
Total number of patients Female Weight at operation, kg, mean SD Height at operation, cm, mean SD Age at operation, days, median (range) 22q11 Deletion Interrupted aortic arch type A Interrupted aortic arch type B Right descending aortic arch Truncus arteriosus communis Transposition of great arteries Aortopulmonary window Bicuspid aortic valve Ventricular septal defect Univentricular heart
Values
649
650
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
Ann Thorac Surg 2015;99:648–52
CONGENITAL HEART
Table 2. Additional Procedures Procedure
n
Ventricular septal defect closure Subaortic incision/myectomy Truncus arteriosus repair Aortopulmonary window repair Arterial switch repair Pulmonary artery banding
18 14 2 2 1 1
can be performed with no early and low late mortality. Reinterventions for aortic arch stenosis may be reduced. The arc-shaped neoaorta features potentially a laminar flow. Bronchus and pulmonary artery compression can be avoided, and the technique can be applied in different anatomic settings. With the subclavian flap, a circular interposition graft is not required to bridge the interruption. Hence, reoperations for graft exchange are not required. However, we observed reinterventions for aortic arch stenosis in 30% of our patients. This finding is in line with other large series, who show reinterventions in 29% to 40% of the patients [10–12]. In the present study, we observed aortic arch stenoses at two locations: stenosis at the proximal end and at the distal end of the patch enlargement. Three patients underwent four surgical procedures owing to proximal aortic arch stenosis. Three of these procedures were performed in the first postoperative month.
Fig 2. Aortic angiogram after interrupted aortic arch repair in lateral view, after the subclavian flap technique (arc-shaped aorta).
Fig 3. Freedom from reintervention at the aortic arch.
Therefore, these reoperations were related to the surgical technique and not to the patch material. In our later experience, early reoperations could be avoided by extending the patch into the ascending aorta, proximal to the location of the aortic cannula. Distal patch stenoses could all be treated with balloon angioplasty. The incidence of distal stenosis could be further reduced by incising the descending aorta in a Y-shaped manner, as described for the Norwood procedure [13]. We expect that reoperations will not be required by applying these modified techniques. Morales and coworkers [14] reported no aortic arch reinterventions in 60 patients by performing a direct anastomosis, extended into the carotid or subclavian artery. The median follow-up time was only 3 years, however. In addition, these excellent results were not confirmed by other investigators who applied the technique of direct anastomosis. The direct anastomosis forms an angular-shaped aorta, instead of the normal arcshaped aorta. That may lead to a turbulent flow, and to hypertension [15, 16]. In contrast, the subclavian flap technique forms an arc-shaped aorta. Further studies including older patients of the present series are warranted to potentially determine laminar flow and normotension. Bronchus and pulmonary artery stenosis have been reported after IAA repair [17, 18]. The potential reason is compression of the underlying structures by the short neoaortic arch. By using the subclavian artery and a patch to bridge the interruption, the length of the aortic arch is not reduced, leaving more space for the bronchus and the pulmonary artery. In our series, there was no reintervention for bronchus or pulmonary artery stenosis. The technique can be applied in different anatomic settings, including transposition of the great arteries, aortopulmonary window, truncus arteriosus communis, right aortic arch, and functionally single ventricle. An exception is type C IAA, as no subclavian artery is lying next to the interruption. A drawback of the technique is the sacrifice of the subclavian artery. However, the resulting minor changes in forearm development did not cause limitations in lifestyle [4, 19].
Ann Thorac Surg 2015;99:648–52
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
651
Table 3. Reinterventions After Interrupted Aortic Arch Repair With Subclavian Flap Technique Indication
Time After Repair (months)
Patch enlargement of aortic arch Aorta asc. þ AV replacement (tissue valve) Patch enlargement of aortic arch þ AV plasty Revision proximal anastomosis Ross-Konno operation VSD patch revision Mitral valve repair RV-PA conduit replacement RV-PA conduit replacement þ truncus valve repair VSD closure Shunt revision Partial CP connection, PA patcha Partial CP connection Total CP connection, PA patcha Total CP connection Enlargement of fenestration
0.6 33.8 0.7 0.1 4.0 4.3 0.1 0.6 38.3 5.7 3.7 3.5 12.1 35.1 10.0 10.0
Balloon angioplasty Stent implantation Stent implantation Balloon valvuloplasty Closure of AP collaterals Closure of fenestration
2.8 14.6 21.3 3.0 51.0 28.8
CONGENITAL HEART
Operations Aortic arch stenosis Aortic arch stenosis Aortic arch stenosis Aortic arch stenosis LVOTO RVOTO MV insufficiency RV-PA-conduit failure RV-PA-conduit failure VSD Shunt stenosis Fontan circulation Fontan circulation Fontan circulation Fontan circulation Failing Fontan Interventions Aortic arch stenosis Aortic arch stenosis PA stenosisa Aortic valve stenosis AP collaterals Cyanosis
Procedure
3.8 59.3 35.4
5.3
8.9
57.4
a
Reinterventions due to pulmonary artery (PA) stenosis were exclusively necessary in patients with univentricular heart, and patients with right ventricle (RV) to PA conduit placement. The PA stenosis was at no time caused by compression of the aortic arch.
AP ¼ aortopulmonary; asc. ¼ ascending; AV ¼ aortic valve; CP ¼ cavopulmonary; LVOTO ¼ left ventricular outflow tract obstruction; MV ¼ mitral valve; RVOTO ¼ right ventricular outflow tract obstruction; VSD ¼ ventricular septal defect.
The study has several limitations. It represents a retrospective, single center experience and enrolls a small number of patients. More accurate assessment of the shape of the created aortic arch would require threedimensional reconstruction by magnetic resonance imaging, which was not performed. Furthermore, no echocardiographic data were included in the current study owing to missing values. In conclusion, the subclavian flap technique for IAA repair forms an arc-shaped aorta without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might not be applicable to bridge a long interruption.
References 1. McCrindle BW, Tchervenkov CI, Konstantinov IE, et al. Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: a Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg 2005;129: 343–50. 2. Hussein A, Iyengar AJ, Jones B, et al. Twenty-three years of single-stage end-to-side anastomosis repair of interrupted aortic arches. J Thorac Cardiovasc Surg 2010;139:942–7. 3. Waldhausen JA, Nahrwold DL. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg 1966;51:532–3.
4. Pandey R, Jackson M, Ajab S, Gladman G, Pozzi M. Subclavian flap repair: review of 399 patients at median followup of fourteen years. Ann Thorac Surg 2006;81:1420–8. 5. Bacha EA, Sawaqed R. Use of the aberrant right subclavian artery in complex aortic arch reconstruction. Ann Thorac Surg 2007;83:1566–8. 6. Sugimori H, Abe M, Kato H, et al. A modification of extended aortic arch anastomosis augmented with subclavian flap aortoplasty for interrupted or hypoplastic aortic arch. J Card Surg 2009;24:561–3. 7. Valeske K, Mueller M, Hijjeh N, Boening A, Schranz D, Akintuerk H. Modified repair of interrupted aortic arch utilizing retroesophageal right subclavian artery based on a neonatal hybrid approach in hypoplastic left heart complex. Thorac Cardiovasc Surg 2012;60:221–5. 8. Chen Q, Modi P, Caputo M, Pawade A. Truncus arteriosus with interrupted aortic arch: successful repair using modified cardiopulmonary bypass and surgical techniques. Ann Thorac Surg 2006;82:1884–6. 9. Siena P, Rajakaruna C, Parry AJ, Caputo M. Reverse subclavian flap and aorto-pulmonary window technique for repair of interrupted aortic arch and truncus arteriosus. Interact Cardiovasc Thorac Surg 2011;13:354–5. 10. Schreiber C, Eicken A, Vogt M, et al. Repair of interrupted aortic arch: results after more than 20 years. Ann Thorac Surg 2000;70:1896–900. 11. Oosterhof T, Azakie A, Freedom RM, Williams WG, McCrindle BW. Associated factors and trends in outcomes of interrupted aortic arch. Ann Thorac Surg 2004;78:1696–702. 12. Jegatheeswaran A, McCrindle BW, Blackstone EH, et al. Persistent risk of subsequent procedures and mortality in patients after interrupted aortic arch repair: a Congenital
CONGENITAL HEART
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BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
Heart Surgeons’ Society study. J Thorac Cardiovasc Surg 2010;140:1059–75. 13. Cleuziou J, Kasnar-Samprec J, H€ orer J, Eicken A, Lange R, Schreiber C. Recoarctation after the Norwood I procedure for hypoplastic left heart syndrome: incidence, risk factors, and treatment options. Ann Thorac Surg 2013;95:935–40. 14. Morales DLS, Scully PT, Braud BE, et al. Interrupted aortic arch repair: aortic arch advancement without a patch minimizes arch reinterventions. Ann Thorac Surg 2006;82: 1577–83. 15. Ou P, Celermajer DS, Raisky O, et al. Angular (Gothic) aortic arch leads to enhanced systolic wave reflection, central aortic stiffness, and increased left ventricular mass late after aortic coarctation repair: evaluation with magnetic resonance flow mapping. J Thorac Cardiovasc Surg 2008;135:62–8.
Ann Thorac Surg 2015;99:648–52
16. Ou P, Bonnet D, Auriacombe L, et al. Late systemic hypertension and aortic arch geometry after successful repair of coarctation of the aorta. Eur Heart J 2004;25:1853–9. 17. Tlaskal T, Vojtovic P, Reich O, Hucin B, Gebauer R, Kucera V. Improved results after the primary repair of interrupted aortic arch: impact of a new management protocol with isolated cerebral perfusion. Eur J Cardiothorac Surg 2010; 38:52–8. 18. Serraf A, Lacour-Gayet F, Robotin M, et al. Repair of interrupted aortic arch: a ten-year experience. J Thorac Cardiovasc Surg 1996;112:1150–60. 19. Shenberger JS, Prophet SA, Waldhausen JA, Davidson WR, Sinoway LI. Left subclavian flap aortoplasty for coarctation of the aorta: effects on forearm vascular function and growth. J Am Coll Cardiol 1989;14:953–9.
Southern Thoracic Surgical Association: Sixty-Second Annual Meeting—Call for Abstracts You are invited to submit abstracts and surgical motion pictures for the Southern Thoracic Surgical Association (STSA) Sixty-Second Annual Meeting to be held November 4-7, 2015 at Disney’s Yacht & Beach Club in Orlando, Florida. To submit an abstract, access the online submission site through the STSA website at www.stsa.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
org beginning in early February. Abstracts must be submitted by Monday, April 6, 2015 at 11:59 PM, Eastern Time. Accepted abstracts will be presented at the STSA Sixty-Second Annual Meeting as oral presentations or surgical videos. Please direct any questions regarding abstract submission to STSA at [email protected] or (800) 685-7872.
Ann Thorac Surg 2015;99:652
0003-4975/$36.00
CONGENITAL HEART
Melchior Burri, MD, Jelena Kasnar-Samprec, MD, PhD, Julie Cleuziou, MD, Christian N€ obauer, MD, Manfred O. Vogt, MD, PhD, R€ udiger Lange, MD, PhD, Christian Schreiber, MD, PhD, and J€ urgen H€ orer, MD, PhD Departments of Cardiovascular Surgery and Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University Munich; and DZHK (German Center for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
Background. With interrupted aortic arch (IAA), a direct anastomosis may produce an angular-shaped aortic arch instead of the normal arc-shaped aorta, when the discontinuity is considerably long. That may lead to aortic stenosis and to compression of the pulmonary artery or the main bronchus. If a tube graft is used, reoperation for graft exchange is inevitable. We demonstrate the results of using the subclavian artery for creating an arc-shaped aorta in IAA repair. Methods. Between February 2006 and October 2012, 23 patients underwent IAA repair using the subclavian artery. The subclavian artery was closed distally, divided, and longitudinally incised from the transected end to the aorta. This flap was used to bridge the gap of the IAA, by forming the posterior wall of a new aortic segment. The arch was completed using glutaraldehyde-fixed autologous pericardium (52%) or homograft (48%).
Results. Median follow-up time was 4.8 years (range, 1.3 to 6.9). There were no early deaths and 1 late death. On postoperative angiographic imaging, the aorta takes an arc-shaped course in all cases. Aortic arch stenosis developed in 7 patients (30%). Four patients were treated interventionally, and 3 surgically. During follow-up, there was no compression of the pulmonary artery or the main bronchus. Conclusions. By using the subclavian artery, an arcshaped aorta can be accomplished without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might be not applicable to bridge a long interruption.
D
The aim of this study was to review our operative experience, and analyze the midterm results regarding mortality and need for reintervention.
irect anastomosis with or without a patch, and interposition of a vascular prosthesis are the most commonly used techniques to repair an interrupted aortic arch (IAA) [1, 2]. The use of a subclavian artery is known for aortic coarctation repair [3, 4]. Recent case reports showed a successful adoption of this technique for IAA repair [5–9]. A subclavian flap is used to bridge the interruption of the aorta on the posterior wall. The neoarch is completed with a patch. We have hypothesized that this technique produces an arc-shaped aorta, leaving more space underneath, and thereby, it might avoid pulmonary artery stenosis or left main bronchial stenosis. In addition, the tension at the site of anastomosis may be lower, reducing the incidence of aortic stenosis [8, 9]. Considering these potential advantages, this modified subclavian flap technique was introduced as the standard technique for IAA repair at the German Heart Center Munich in 2006.
Accepted for publication Sept 23, 2014. Address correspondence to Dr Burri, Department of Cardiovascular Surgery, German Heart Center Munich, Technical University Munich, Lazarettstrasse 36, Munich D-80636, Germany; e-mail: burri@dhm. mhn.de.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
(Ann Thorac Surg 2015;99:648–52) Ó 2015 by The Society of Thoracic Surgeons
Patients and Methods Between February 2006 and October 2012, 26 consecutive patients with IAA underwent surgery at the German Heart Center Munich. Three patients did not undergo operation by the subclavian flap technique and were excluded. One patient had type C IAA. A direct anastomosis was performed in this patient. One patient underwent Norwood type anastomosis with direct anastomosis, and in 1 patient, a conduit was placed. In both of the 2 latter patients, the reason for not applying the subclavian flap technique was the presence of an alternate team of surgeons, not the anatomy of the patient. Characteristics of the remaining 23 patients included are shown in Table 1. Median follow-up time was 4.8 years (range, 1.3 to 6.9; mean 4.2). Follow-up was complete. The operation was performed using aortic, pulmonary, and bicaval cannulation. The aortic arch was reconstructed under deep hypothermic circulatory arrest. All 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.09.053
Ann Thorac Surg 2015;99:648–52
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
Table 1. Patient Characteristics Characteristics
23 11 (47) 3.1 0.6 50 3 11 (6–45) 12 (52) 5 (22) 18 (78) 2 (9) 2 (9) 2 (9) 2 (9) 10 (43) 21 (91) 2 (9)
Values are n (%), unless otherwise indicated.
ductal tissue was removed. In patients with type B interruption, the distal ascending aorta was incised at the left lateral wall. The left subclavian artery was closed distally, divided, and opened longitudinally. This subclavian flap was then turned toward the ascending aorta and anastomosed with the incision to construct the posterior aspect of the neoaortic arch (Fig 1). In patients with type A interruption, the left subclavian artery was turned toward the descending aorta. Either homograft (n ¼ 11) or autologous glutaraldehyde-fixed pericardium (n ¼ 12) was used to complete the anterior wall of the aorta. In 3 patients with type B interruption, a right lusorian artery was used instead of the left subclavian artery. Mean circulatory arrest time was 37 8 minutes. Additional procedures were performed at initial operation because of concomitant cardiac anomalies (Table 2). Descriptive statistics are described as frequencies and percentages for categorical variables. Continuous variables are expressed as mean value and standard deviation, if normally distributed, or as median with range if not normally distributed. Confidence interval (CI) is reported as 95% CI. Probabilities of freedom from death and of freedom from reintervention after the initial operation were calculated using the Kaplan-Meier
method. In calculations for reinterventions, death was stated as censoring. All statistical calculations were performed using the R environment (version 2.13.1; R Foundation, Vienna, Austria). The Review Board approved the study and waived the need for informed consent from the parents owing to lack of any patient identifiers and the retrospective nature of the study. All authors had full access to the data, and take full responsibility for its integrity.
Results There was no early death. One patient with severe subaortic stenosis and hypoplastic ascending aorta died of circulatory and respiratory failure 3 years after the initial operation. He underwent a Ross-Konno operation 4 months after the operation. During follow-up, angiography of the aortic arch was performed in 12 patients. In 5 patients, the indication was hemodynamic evaluation before conduit exchange, Glenn procedure, or ventricular septal defect closure. In 5 patients, the indication was evaluation of an echocardiographically suspected restenosis of the aortic arch. In 2 patients, the indication was cardiopulmonary instability due to low oxygen saturation. By using the subclavian flap technique, an arc-shaped aortic arch was achieved (Fig 2). Estimated freedom from reintervention due to aortic arch stenosis was 78% (95% CI: 63% to 97%) at 1 year, and 68% (95% CI: 51% to 91%) at 5 years (Fig 3). In 5 patients, the stenosis was located at the distal end of the patch enlargement. These patients were successfully treated with percutaneous balloon angioplasty. In 3 patients, the stenosis was located at the proximal end of the patch enlargement. These patients were successfully treated surgically. Freedom from all types of reinterventions was 52% (95% CI: 35% to 77%) at 1 year and 46% (95% CI: 29% to 73%) at 5 years. Table 3 shows all reinterventions performed during follow-up.
Comment Interrupted aortic arch reconstruction with the subclavian artery has been reported in individual cases only. In the present study, an arc-shaped aorta was accomplished by using the subclavian artery in 23 patients. The procedure Fig 1. Reconstruction of aortic arch with left subclavian artery. (A) The left subclavian artery is divided and longitudinally incised. (B) The subclavian artery is based as the posterior wall of the aortic arch before completion with patch.
CONGENITAL HEART
Total number of patients Female Weight at operation, kg, mean SD Height at operation, cm, mean SD Age at operation, days, median (range) 22q11 Deletion Interrupted aortic arch type A Interrupted aortic arch type B Right descending aortic arch Truncus arteriosus communis Transposition of great arteries Aortopulmonary window Bicuspid aortic valve Ventricular septal defect Univentricular heart
Values
649
650
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
Ann Thorac Surg 2015;99:648–52
CONGENITAL HEART
Table 2. Additional Procedures Procedure
n
Ventricular septal defect closure Subaortic incision/myectomy Truncus arteriosus repair Aortopulmonary window repair Arterial switch repair Pulmonary artery banding
18 14 2 2 1 1
can be performed with no early and low late mortality. Reinterventions for aortic arch stenosis may be reduced. The arc-shaped neoaorta features potentially a laminar flow. Bronchus and pulmonary artery compression can be avoided, and the technique can be applied in different anatomic settings. With the subclavian flap, a circular interposition graft is not required to bridge the interruption. Hence, reoperations for graft exchange are not required. However, we observed reinterventions for aortic arch stenosis in 30% of our patients. This finding is in line with other large series, who show reinterventions in 29% to 40% of the patients [10–12]. In the present study, we observed aortic arch stenoses at two locations: stenosis at the proximal end and at the distal end of the patch enlargement. Three patients underwent four surgical procedures owing to proximal aortic arch stenosis. Three of these procedures were performed in the first postoperative month.
Fig 2. Aortic angiogram after interrupted aortic arch repair in lateral view, after the subclavian flap technique (arc-shaped aorta).
Fig 3. Freedom from reintervention at the aortic arch.
Therefore, these reoperations were related to the surgical technique and not to the patch material. In our later experience, early reoperations could be avoided by extending the patch into the ascending aorta, proximal to the location of the aortic cannula. Distal patch stenoses could all be treated with balloon angioplasty. The incidence of distal stenosis could be further reduced by incising the descending aorta in a Y-shaped manner, as described for the Norwood procedure [13]. We expect that reoperations will not be required by applying these modified techniques. Morales and coworkers [14] reported no aortic arch reinterventions in 60 patients by performing a direct anastomosis, extended into the carotid or subclavian artery. The median follow-up time was only 3 years, however. In addition, these excellent results were not confirmed by other investigators who applied the technique of direct anastomosis. The direct anastomosis forms an angular-shaped aorta, instead of the normal arcshaped aorta. That may lead to a turbulent flow, and to hypertension [15, 16]. In contrast, the subclavian flap technique forms an arc-shaped aorta. Further studies including older patients of the present series are warranted to potentially determine laminar flow and normotension. Bronchus and pulmonary artery stenosis have been reported after IAA repair [17, 18]. The potential reason is compression of the underlying structures by the short neoaortic arch. By using the subclavian artery and a patch to bridge the interruption, the length of the aortic arch is not reduced, leaving more space for the bronchus and the pulmonary artery. In our series, there was no reintervention for bronchus or pulmonary artery stenosis. The technique can be applied in different anatomic settings, including transposition of the great arteries, aortopulmonary window, truncus arteriosus communis, right aortic arch, and functionally single ventricle. An exception is type C IAA, as no subclavian artery is lying next to the interruption. A drawback of the technique is the sacrifice of the subclavian artery. However, the resulting minor changes in forearm development did not cause limitations in lifestyle [4, 19].
Ann Thorac Surg 2015;99:648–52
BURRI ET AL IAA REPAIR WITH SUBCLAVIAN FLAP
651
Table 3. Reinterventions After Interrupted Aortic Arch Repair With Subclavian Flap Technique Indication
Time After Repair (months)
Patch enlargement of aortic arch Aorta asc. þ AV replacement (tissue valve) Patch enlargement of aortic arch þ AV plasty Revision proximal anastomosis Ross-Konno operation VSD patch revision Mitral valve repair RV-PA conduit replacement RV-PA conduit replacement þ truncus valve repair VSD closure Shunt revision Partial CP connection, PA patcha Partial CP connection Total CP connection, PA patcha Total CP connection Enlargement of fenestration
0.6 33.8 0.7 0.1 4.0 4.3 0.1 0.6 38.3 5.7 3.7 3.5 12.1 35.1 10.0 10.0
Balloon angioplasty Stent implantation Stent implantation Balloon valvuloplasty Closure of AP collaterals Closure of fenestration
2.8 14.6 21.3 3.0 51.0 28.8
CONGENITAL HEART
Operations Aortic arch stenosis Aortic arch stenosis Aortic arch stenosis Aortic arch stenosis LVOTO RVOTO MV insufficiency RV-PA-conduit failure RV-PA-conduit failure VSD Shunt stenosis Fontan circulation Fontan circulation Fontan circulation Fontan circulation Failing Fontan Interventions Aortic arch stenosis Aortic arch stenosis PA stenosisa Aortic valve stenosis AP collaterals Cyanosis
Procedure
3.8 59.3 35.4
5.3
8.9
57.4
a
Reinterventions due to pulmonary artery (PA) stenosis were exclusively necessary in patients with univentricular heart, and patients with right ventricle (RV) to PA conduit placement. The PA stenosis was at no time caused by compression of the aortic arch.
AP ¼ aortopulmonary; asc. ¼ ascending; AV ¼ aortic valve; CP ¼ cavopulmonary; LVOTO ¼ left ventricular outflow tract obstruction; MV ¼ mitral valve; RVOTO ¼ right ventricular outflow tract obstruction; VSD ¼ ventricular septal defect.
The study has several limitations. It represents a retrospective, single center experience and enrolls a small number of patients. More accurate assessment of the shape of the created aortic arch would require threedimensional reconstruction by magnetic resonance imaging, which was not performed. Furthermore, no echocardiographic data were included in the current study owing to missing values. In conclusion, the subclavian flap technique for IAA repair forms an arc-shaped aorta without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might not be applicable to bridge a long interruption.
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Southern Thoracic Surgical Association: Sixty-Second Annual Meeting—Call for Abstracts You are invited to submit abstracts and surgical motion pictures for the Southern Thoracic Surgical Association (STSA) Sixty-Second Annual Meeting to be held November 4-7, 2015 at Disney’s Yacht & Beach Club in Orlando, Florida. To submit an abstract, access the online submission site through the STSA website at www.stsa.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
org beginning in early February. Abstracts must be submitted by Monday, April 6, 2015 at 11:59 PM, Eastern Time. Accepted abstracts will be presented at the STSA Sixty-Second Annual Meeting as oral presentations or surgical videos. Please direct any questions regarding abstract submission to STSA at [email protected] or (800) 685-7872.
Ann Thorac Surg 2015;99:652
0003-4975/$36.00