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Extended end-to-end anastomosis with modified reverse subclavian flap angioplasty
Extended End-to-End Anastomosis With Modified Reverse Subclavian Flap Angioplasty Alessandro Giamberti, MD, Giuseppe Pome´, MD, Gianfranco Butera, MD, Luca Rosti, MD, Aldo Agnetti, MD, and Alessandro Frigiola, MD Division of Cardiac Surgery, Hospital San Donato, San Donato Milanese, and Department of Pediatric Cardiology, University of Parma, Parma, Italy
We report a surgical treatment for neonatal aortic coarctatin associated with distal aortic arch hypoplasia. This technique offers the possibility for augmentation of the aortic arch without sacrificing the subclavian artery or using prosthetic patch material. The procedure was successfully performed in 5 patients. (Ann Thorac Surg 2001;72:951–2) © 2001 by The Society of Thoracic Surgeons
N
eonatal aortic coarctation is frequently associated with hypoplasia of the transverse arch [1]. In more than 80% of cases the hypoplasia is distal, involving the segment between the left carotid and the subclavian artery [1]. An extended end-to-end anastomosis, sometimes associated with an increasing of the diameter of the aortic arch using the tissue of the left subclavian artery (reverse flap), seems to be the treatment of choice [1, 2]. We report our technique of end-to-end anastomosis plus reverse flap without the need of sacrificing the subclavian artery.
Technique Through a left posterolateral thoracotomy in the third intercostal space, the transverse arch, innominate, left carotid, and left subclavian arteries, ductus arteriosus, and descending aorta are widely dissected. The proximal clamp is placed, clamping the aortic arch proximal to the left carotid artery, together with the distal portion of the left carotid artery. The left subclavian artery is separately clamped close to its thoracic exit. Finally, a third clamp or a vascular clip is placed between the left subclavian artery and the ductus arteriosus. The segment formed by the hypoplastic arch and the left subclavian artery is incised longitudinally until and including the origin of the left carotid artery (Fig 1). A continuous suture with 8-0 polypropylene is used to anastomose the dorsal and ventral walls of the two incised vessels (Fig 2). The third clamp or the vascular clip is removed, and the ductus arteriosus is ligated. The descending aorta is clamped distally at level of the first intercostal arteries. The coarctation is widely resected, with removal of all the ductus arteriosus tissue. The inferior border of the transverse
Fig 1. The line incision involving the hypoplastic distal aortic arch, the left subclavian artery, and the left carotid artery.
arch is incised toward the concavity of the arch until the origin of the left carotid artery. The descending aorta is incised posteriorly (Fig 3). The extended end-to-end anastomosis is performed with continuous 7-0 polypropylene suture (Fig 4).
Results Five neonates (mean age, 4 days; mean body weight, 2.4 kg) with aortic coarctation and hypoplastic distal aortic arch underwent this technique of extended endto-end anastomosis plus modified reverse flap. Associated cardiac malformations were large ventricular septal defect in a 1.8-kg patient; multiple ventricular septal defects in 1; double-inlet left ventricle and transposition of great arteries in 1. A concomitant pulmonary artery banding was performed in these 3 patients. There were no hospital and late deaths. In a mean follow-up of 16 months (range, 4 to 48 months), the patient with the ventricular septal defect and the patient with multiple ventricular septal defects underwent successful late repair of their defects. The absence of blood
Accepted for publication April 26, 2001. Address reprint requests to Dr Giamberti, Divisione di Cardiochirurgia, Istituto Policlinico San Donato, Via Morandi, 30, 20097 San Donato Milanese, Italy. e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Enlargement of the hypoplastic distal aortic arch. 0003-4975/01/$20.00 PII S0003-4975(01)02483-0
952
HOW TO DO IT GIAMBERTI ET AL MODIFIED REVERSE SUBCLAVIAN FLAP ANGIOPLASTY
Ann Thorac Surg 2001;72:951–2
Fig 3. After resection of the coarctation and the ductus arteriosus tissue, the transverse arch is incised until the origin of the left carotid artery. The descending aorta is incised posteriorly.
pressure gradient and the flow through the left subclavian artery were demonstrated clinically and with echocardiography in all patients. An angiography was performed in 1 patient (Fig 5).
Comment Extended end-to-end anastomosis sometimes associated with an aortic arch enlargement seems to be the treatment of choice for neonatal hypoplastic aortic arch in most institutions [1, 2]. Several surgical techniques have been published demonstrating the technique to enlarge the aortic arch by using the left subclavian artery [3–5] or a prosthetic patch [6]. Our technique offers a possibility for a successful surgical expansion of the aortic arch size and at the same time conserves the flow through the left subclavian artery. Different complications have been reported after subclavian artery ligation [3, 4, 7]. Catastrophic ischemia with gangrene requiring amputation of the left arm or left fingers, ischemic injury of the brachial plexus, subclavian steal syndrome, diminution in both longitudinal growth of the long bones and muscle thickness, decrease in blood flow and blood pressure on the operated side, cooler arm, hypotrophy and arm claudication with strenuous exercise can occur immediately or later in the follow-up [3, 4, 7]. When these complications occur, an augmentation of the blood flow is needed by direct subclavian-to-carotid anastomosis or by carotid-tosubclavian graft bypass [7, 8]. In our technique no prosthetic materials are needed, avoiding the risk of false aneurysm. A vascular clamp or a clip just below the left subclavian artery, leaving open the ductus arteriosus, permits the perfusion of the infe-
Fig 4. Final result after the extended end-to-end anastomosis.
Fig 5. Aortic angiography showing the flow in the left subclavian artery 1 year after the procedure.
rior part of the body during the surgical aortic arch enlargement time. As suggested by the largest series of arterial switch operations [9], the satisfactory growth of the neonatal circular anastomosis permits the use of nonreabsorbable continuous suture for the aortic arch enlargement and for the end-to-end anastomosis. A wide dissection of the entire aorta, an extended end-to-end anastomosis, and a complete resection of the ductus tissue are also fundamental. In conclusion, creating a second left-sided brachiocephalic trunk offers a simple, safe, and effective surgical possibility for correction of neonatal coarctation with distal aortic arch hypoplasia, preserving the flow to the left arm.
References 1. Lacour-Gayet F, Bruniaux J, Serraf A, et al. Hypoplastic transverse arch and coarctation in neonates. J Thorac Cardiovasc Surg 1990;100:808–16. 2. Pfammatter JP, Ziemer G, Kaulitz R, Heinemmann MK, Luhmer I, Kallfelz HC. Isolated aortic coarctation in neonates and infants: results of resection and end-to-end anastomosis. Ann Thorac Surg 1996;62:778– 83. 3. Vincent JG, Daniels O, van Oort A, Lacquet LK. Hypoplastic aortic arch with aortic coarctation: surgical correction. J Thorac Cardiovasc Surg 1985;89:465– 8. 4. Meier MA, Lucchese FA, Jazbik W, Nesralla IA, Mendonca JT. A new technique for repair of aortic coarctation. J Thorac Cardiovasc Surg 1986;92:1005–12. 5. Hovaguimian H, Senthilnathan V, Igiudbashian JP, McIrvin DM, Starr A. Coarctation repair: modification of end-to-end anastomosis with subclavian flap angioplasty. Ann Thorac Surg 1998;65:1751– 4. 6. Ungerleider RM, Ebert PA. Indications and techniques of midline approach to aortic coarctation in infants and children. Ann Thorac Surg 1987;44:517–22. 7. Wells WJ, Castro LJ. Arm ischemia after subclavian flap angioplasty: repair by carotid-subclavian bypass. Ann Thorac Surg 2000;69:1574– 6. 8. Diemont FF, Chemla ES, Julia PL, Sirieix D, Fabiani JN. Upper limb ischemia after subclavian flap aortoplasty: unusual longterm complication. Ann Thorac Surg 2000;69:1576– 8. 9. Planche´ C, Bruniaux J, Lacour-Gayet F, et al. Switch operation for transposition of great arteries in neonates: a study of 120 patients. J Thorac Cardiovasc Surg1988;96:354– 63.
We report a surgical treatment for neonatal aortic coarctatin associated with distal aortic arch hypoplasia. This technique offers the possibility for augmentation of the aortic arch without sacrificing the subclavian artery or using prosthetic patch material. The procedure was successfully performed in 5 patients. (Ann Thorac Surg 2001;72:951–2) © 2001 by The Society of Thoracic Surgeons
N
eonatal aortic coarctation is frequently associated with hypoplasia of the transverse arch [1]. In more than 80% of cases the hypoplasia is distal, involving the segment between the left carotid and the subclavian artery [1]. An extended end-to-end anastomosis, sometimes associated with an increasing of the diameter of the aortic arch using the tissue of the left subclavian artery (reverse flap), seems to be the treatment of choice [1, 2]. We report our technique of end-to-end anastomosis plus reverse flap without the need of sacrificing the subclavian artery.
Technique Through a left posterolateral thoracotomy in the third intercostal space, the transverse arch, innominate, left carotid, and left subclavian arteries, ductus arteriosus, and descending aorta are widely dissected. The proximal clamp is placed, clamping the aortic arch proximal to the left carotid artery, together with the distal portion of the left carotid artery. The left subclavian artery is separately clamped close to its thoracic exit. Finally, a third clamp or a vascular clip is placed between the left subclavian artery and the ductus arteriosus. The segment formed by the hypoplastic arch and the left subclavian artery is incised longitudinally until and including the origin of the left carotid artery (Fig 1). A continuous suture with 8-0 polypropylene is used to anastomose the dorsal and ventral walls of the two incised vessels (Fig 2). The third clamp or the vascular clip is removed, and the ductus arteriosus is ligated. The descending aorta is clamped distally at level of the first intercostal arteries. The coarctation is widely resected, with removal of all the ductus arteriosus tissue. The inferior border of the transverse
Fig 1. The line incision involving the hypoplastic distal aortic arch, the left subclavian artery, and the left carotid artery.
arch is incised toward the concavity of the arch until the origin of the left carotid artery. The descending aorta is incised posteriorly (Fig 3). The extended end-to-end anastomosis is performed with continuous 7-0 polypropylene suture (Fig 4).
Results Five neonates (mean age, 4 days; mean body weight, 2.4 kg) with aortic coarctation and hypoplastic distal aortic arch underwent this technique of extended endto-end anastomosis plus modified reverse flap. Associated cardiac malformations were large ventricular septal defect in a 1.8-kg patient; multiple ventricular septal defects in 1; double-inlet left ventricle and transposition of great arteries in 1. A concomitant pulmonary artery banding was performed in these 3 patients. There were no hospital and late deaths. In a mean follow-up of 16 months (range, 4 to 48 months), the patient with the ventricular septal defect and the patient with multiple ventricular septal defects underwent successful late repair of their defects. The absence of blood
Accepted for publication April 26, 2001. Address reprint requests to Dr Giamberti, Divisione di Cardiochirurgia, Istituto Policlinico San Donato, Via Morandi, 30, 20097 San Donato Milanese, Italy. e-mail: [email protected].
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 2. Enlargement of the hypoplastic distal aortic arch. 0003-4975/01/$20.00 PII S0003-4975(01)02483-0
952
HOW TO DO IT GIAMBERTI ET AL MODIFIED REVERSE SUBCLAVIAN FLAP ANGIOPLASTY
Ann Thorac Surg 2001;72:951–2
Fig 3. After resection of the coarctation and the ductus arteriosus tissue, the transverse arch is incised until the origin of the left carotid artery. The descending aorta is incised posteriorly.
pressure gradient and the flow through the left subclavian artery were demonstrated clinically and with echocardiography in all patients. An angiography was performed in 1 patient (Fig 5).
Comment Extended end-to-end anastomosis sometimes associated with an aortic arch enlargement seems to be the treatment of choice for neonatal hypoplastic aortic arch in most institutions [1, 2]. Several surgical techniques have been published demonstrating the technique to enlarge the aortic arch by using the left subclavian artery [3–5] or a prosthetic patch [6]. Our technique offers a possibility for a successful surgical expansion of the aortic arch size and at the same time conserves the flow through the left subclavian artery. Different complications have been reported after subclavian artery ligation [3, 4, 7]. Catastrophic ischemia with gangrene requiring amputation of the left arm or left fingers, ischemic injury of the brachial plexus, subclavian steal syndrome, diminution in both longitudinal growth of the long bones and muscle thickness, decrease in blood flow and blood pressure on the operated side, cooler arm, hypotrophy and arm claudication with strenuous exercise can occur immediately or later in the follow-up [3, 4, 7]. When these complications occur, an augmentation of the blood flow is needed by direct subclavian-to-carotid anastomosis or by carotid-tosubclavian graft bypass [7, 8]. In our technique no prosthetic materials are needed, avoiding the risk of false aneurysm. A vascular clamp or a clip just below the left subclavian artery, leaving open the ductus arteriosus, permits the perfusion of the infe-
Fig 4. Final result after the extended end-to-end anastomosis.
Fig 5. Aortic angiography showing the flow in the left subclavian artery 1 year after the procedure.
rior part of the body during the surgical aortic arch enlargement time. As suggested by the largest series of arterial switch operations [9], the satisfactory growth of the neonatal circular anastomosis permits the use of nonreabsorbable continuous suture for the aortic arch enlargement and for the end-to-end anastomosis. A wide dissection of the entire aorta, an extended end-to-end anastomosis, and a complete resection of the ductus tissue are also fundamental. In conclusion, creating a second left-sided brachiocephalic trunk offers a simple, safe, and effective surgical possibility for correction of neonatal coarctation with distal aortic arch hypoplasia, preserving the flow to the left arm.
References 1. Lacour-Gayet F, Bruniaux J, Serraf A, et al. Hypoplastic transverse arch and coarctation in neonates. J Thorac Cardiovasc Surg 1990;100:808–16. 2. Pfammatter JP, Ziemer G, Kaulitz R, Heinemmann MK, Luhmer I, Kallfelz HC. Isolated aortic coarctation in neonates and infants: results of resection and end-to-end anastomosis. Ann Thorac Surg 1996;62:778– 83. 3. Vincent JG, Daniels O, van Oort A, Lacquet LK. Hypoplastic aortic arch with aortic coarctation: surgical correction. J Thorac Cardiovasc Surg 1985;89:465– 8. 4. Meier MA, Lucchese FA, Jazbik W, Nesralla IA, Mendonca JT. A new technique for repair of aortic coarctation. J Thorac Cardiovasc Surg 1986;92:1005–12. 5. Hovaguimian H, Senthilnathan V, Igiudbashian JP, McIrvin DM, Starr A. Coarctation repair: modification of end-to-end anastomosis with subclavian flap angioplasty. Ann Thorac Surg 1998;65:1751– 4. 6. Ungerleider RM, Ebert PA. Indications and techniques of midline approach to aortic coarctation in infants and children. Ann Thorac Surg 1987;44:517–22. 7. Wells WJ, Castro LJ. Arm ischemia after subclavian flap angioplasty: repair by carotid-subclavian bypass. Ann Thorac Surg 2000;69:1574– 6. 8. Diemont FF, Chemla ES, Julia PL, Sirieix D, Fabiani JN. Upper limb ischemia after subclavian flap aortoplasty: unusual longterm complication. Ann Thorac Surg 2000;69:1576– 8. 9. Planche´ C, Bruniaux J, Lacour-Gayet F, et al. Switch operation for transposition of great arteries in neonates: a study of 120 patients. J Thorac Cardiovasc Surg1988;96:354– 63.