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EXTRAPLEURAL APPROACH FOR COARCTATION OF THE AORTA
EXTRAPLEURAL APPROACH FOR COARCTATION OF THE AORTA H. B Shumacker, Jr., M.D., I. MandeWaum, and Harold King, M.D., Indianapolis,
M.D.*
Ind.
N a previous communication, certain advantages were noted in the extrapleural approach for patent ductus arteriosus in critically ill infants. 5 It was pos sible gently to retract the lung in its pleural envelope with a minimum of com pression and disturbance of pulmonary function. Exposure was good and there were no postoperative pulmonary complications. This technique has been recently extended to include 5 patients with coaretation of the aorta, associated with a ligamentum arteriosum in one, a small patent ductus in 3, and a large ductus in the fifth. In the latter patient, the coaretation was of the preductal type, whereas, in 4, the more common postductal variety was found. In all, it was possible to resect easily the coarcted segment and perform an end-to-end anastomosis.
I
TECHNIQUE
A standard left posterolateral thoracotomy incision is made. The lattissimus dorsi and serratus anterior muscles are transected. The fourth intercostal space is identified and the external and internal intercostal muscles are severed by sharp dissection. The pleura appears as a firm, taut structure with the lung beneath it moving with respiration. The pleura is gently separated from the parietes by blunt finger dissection. The handle of the scalpel may also be used to free the pleura from the chest wall. As one proceeds, the pleura and lung fall away, and the blunt dissection is carefully continued posteriorly. Because of the tortuous dilated intercostal arteries, caution and gentleness are required as the descending thoracic aorta is approached. At this stage, an en larged intercostal artery may simulate the left subclavian artery. The pleura overlying the aorta appears pleated and redundant. As this is reflected medially, the descending thoracic aorta is exposed. The supreme intercostal vein is divided between ligatures. The left subclavian artery, the aortic arch, and the Prom the Department of Surgery and The Heart Research Center, Indiana University Medical Center, Indianapolis, Ind. Aided by grants from the James Whitcomb Riley Association, the Indiana Heart Associa tion, and the U. S. Public Health Service. Received for publication Sept. 29, 1961. •Postdoctoral Fellow, U. S. Public Health Service, National Heart Institute. 204
Vol. 44, No. 2 August, 1962
COARCTATION OF AORTA
205
descending aorta are isolated. If a patent ductus arteriosus is present, it is occluded with two atraumatie vascular clamps, divided and closed with a con tinuous arterial suture. Two atraumatie vascular clamps are then applied to the aorta above and below the eoarcted segment. This area is excised and an end-to-end anastomosis is performed with a continuous 6-0 Merselene suture for the posterior layer and 6-0 Merselene interrupted sutures for the anterior layer. The clamps are removed and the lungs are inflated. The wound is closed with out catheter drainage.
Fig. 1.—The extrapleural approach in coarctation of the aorta. 1, The standard left posterolateral thoracotomy incision. 2, Finger dissection separates the pleura from the parietes and an enlarged, tortuous in tercostal artery is seen posteriorly. 3, The area of coarctation is exposed and the lung and its pleural envelope are gently retracted anteriorly. i, The appearance of the aorta after resection and anastomosns has been carried out. DISCUSSION
In 1945, Crafoord and Nylin 2 were the first to report 2 successful cases of resection of a coarctation of the aorta with an end-to-end anastomosis. The transpleural approach was utilized. Subsequent experiences from other insti tutions confirmed the fact that this procedure could be performed with low morbidity and mortality. 1 ' 3 ' 4 Recent experiences with the extrapleural approach for patent ductus ar teriosus in critically ill infants suggested to us the possibility that this might be useful in coarctation of the aorta. 5 Indeed, this has proved to be the case. The exposure has been excellent in 5 patients with coarctation who were 2i/ 2 ,
206
SHUMACKEB,
MANDELBAUM, KING
J. Thoracic and Cardiovas. Surg.
314, 6, 10, and 10 years of age. One patient had a preductal coarctation with a narrow proximal descending thoracic aorta. After adequate mobilization of the aorta, it was possible to resect the coarcted segment and narrowed area and perform an anastomosis between the base of the aortic arch and the descend ing thoracic aorta. Resection and anastomosis were carried out in 4 children with postductal coarctation. All obtained good results. During the operative procedure, it was possible to proceed with the dissec tion without frequent repositioning of retractors. There was minimal compres sion of the pulmonary parenchyma and no drying of the surface of the lung. Should one inadvertently tear the pleura, closure is easy since the pleura is so adequately mobilized. The postoperative course of each patient was smooth and without complication. The extrapleural approach has proved to be useful in infants and small children. Whether it may prove to be applicable in older children and in adults, we cannot say at this time. SUMMARY
The extrapleural approach for patent ductus arteriosus has been extended to the treatment of coarctation of the aorta in children. It has provided ex cellent exposure and the patients so treated have had a smooth operative and postoperative course. ADDENDUM A number of additional patients have subsequently been treated successfully in similar fashion. REFERENCES 1. Bing, B. J., Handelsman, J . C , Campbell, J . A., Griswold, H. E., and Blalock, A.: The Surgical Treatment and the Physiopathology of Coarctation of the Aorta, Ann. Surg. 128: 803, 1948. 2. Crafoord, C , and Nylin, G.: Congenital Coarctation of the Aorta and Its Surgical Treat ment, J . THORACIC SURG. 14: 347,
1945.
3. Gross, B. E., and Hufnagel, C. A . : Coarctation of the Aorta. Experimental Studies Begarding I t s Surgical Correction, New England J . Med. 233: 287, 1945. 4. Gross, E. E . : Coarctation of the A o r t a : Surgical Treatment of One Hundred Cases, Circulation 1: 41, 1950. 5. King, H., and Mandelbaum, I . : Extrapleural Approach for Patent Ductus Arteriosus, Surgery 5 1 : 277, 1962.
M.D.*
Ind.
N a previous communication, certain advantages were noted in the extrapleural approach for patent ductus arteriosus in critically ill infants. 5 It was pos sible gently to retract the lung in its pleural envelope with a minimum of com pression and disturbance of pulmonary function. Exposure was good and there were no postoperative pulmonary complications. This technique has been recently extended to include 5 patients with coaretation of the aorta, associated with a ligamentum arteriosum in one, a small patent ductus in 3, and a large ductus in the fifth. In the latter patient, the coaretation was of the preductal type, whereas, in 4, the more common postductal variety was found. In all, it was possible to resect easily the coarcted segment and perform an end-to-end anastomosis.
I
TECHNIQUE
A standard left posterolateral thoracotomy incision is made. The lattissimus dorsi and serratus anterior muscles are transected. The fourth intercostal space is identified and the external and internal intercostal muscles are severed by sharp dissection. The pleura appears as a firm, taut structure with the lung beneath it moving with respiration. The pleura is gently separated from the parietes by blunt finger dissection. The handle of the scalpel may also be used to free the pleura from the chest wall. As one proceeds, the pleura and lung fall away, and the blunt dissection is carefully continued posteriorly. Because of the tortuous dilated intercostal arteries, caution and gentleness are required as the descending thoracic aorta is approached. At this stage, an en larged intercostal artery may simulate the left subclavian artery. The pleura overlying the aorta appears pleated and redundant. As this is reflected medially, the descending thoracic aorta is exposed. The supreme intercostal vein is divided between ligatures. The left subclavian artery, the aortic arch, and the Prom the Department of Surgery and The Heart Research Center, Indiana University Medical Center, Indianapolis, Ind. Aided by grants from the James Whitcomb Riley Association, the Indiana Heart Associa tion, and the U. S. Public Health Service. Received for publication Sept. 29, 1961. •Postdoctoral Fellow, U. S. Public Health Service, National Heart Institute. 204
Vol. 44, No. 2 August, 1962
COARCTATION OF AORTA
205
descending aorta are isolated. If a patent ductus arteriosus is present, it is occluded with two atraumatie vascular clamps, divided and closed with a con tinuous arterial suture. Two atraumatie vascular clamps are then applied to the aorta above and below the eoarcted segment. This area is excised and an end-to-end anastomosis is performed with a continuous 6-0 Merselene suture for the posterior layer and 6-0 Merselene interrupted sutures for the anterior layer. The clamps are removed and the lungs are inflated. The wound is closed with out catheter drainage.
Fig. 1.—The extrapleural approach in coarctation of the aorta. 1, The standard left posterolateral thoracotomy incision. 2, Finger dissection separates the pleura from the parietes and an enlarged, tortuous in tercostal artery is seen posteriorly. 3, The area of coarctation is exposed and the lung and its pleural envelope are gently retracted anteriorly. i, The appearance of the aorta after resection and anastomosns has been carried out. DISCUSSION
In 1945, Crafoord and Nylin 2 were the first to report 2 successful cases of resection of a coarctation of the aorta with an end-to-end anastomosis. The transpleural approach was utilized. Subsequent experiences from other insti tutions confirmed the fact that this procedure could be performed with low morbidity and mortality. 1 ' 3 ' 4 Recent experiences with the extrapleural approach for patent ductus ar teriosus in critically ill infants suggested to us the possibility that this might be useful in coarctation of the aorta. 5 Indeed, this has proved to be the case. The exposure has been excellent in 5 patients with coarctation who were 2i/ 2 ,
206
SHUMACKEB,
MANDELBAUM, KING
J. Thoracic and Cardiovas. Surg.
314, 6, 10, and 10 years of age. One patient had a preductal coarctation with a narrow proximal descending thoracic aorta. After adequate mobilization of the aorta, it was possible to resect the coarcted segment and narrowed area and perform an anastomosis between the base of the aortic arch and the descend ing thoracic aorta. Resection and anastomosis were carried out in 4 children with postductal coarctation. All obtained good results. During the operative procedure, it was possible to proceed with the dissec tion without frequent repositioning of retractors. There was minimal compres sion of the pulmonary parenchyma and no drying of the surface of the lung. Should one inadvertently tear the pleura, closure is easy since the pleura is so adequately mobilized. The postoperative course of each patient was smooth and without complication. The extrapleural approach has proved to be useful in infants and small children. Whether it may prove to be applicable in older children and in adults, we cannot say at this time. SUMMARY
The extrapleural approach for patent ductus arteriosus has been extended to the treatment of coarctation of the aorta in children. It has provided ex cellent exposure and the patients so treated have had a smooth operative and postoperative course. ADDENDUM A number of additional patients have subsequently been treated successfully in similar fashion. REFERENCES 1. Bing, B. J., Handelsman, J . C , Campbell, J . A., Griswold, H. E., and Blalock, A.: The Surgical Treatment and the Physiopathology of Coarctation of the Aorta, Ann. Surg. 128: 803, 1948. 2. Crafoord, C , and Nylin, G.: Congenital Coarctation of the Aorta and Its Surgical Treat ment, J . THORACIC SURG. 14: 347,
1945.
3. Gross, B. E., and Hufnagel, C. A . : Coarctation of the Aorta. Experimental Studies Begarding I t s Surgical Correction, New England J . Med. 233: 287, 1945. 4. Gross, E. E . : Coarctation of the A o r t a : Surgical Treatment of One Hundred Cases, Circulation 1: 41, 1950. 5. King, H., and Mandelbaum, I . : Extrapleural Approach for Patent Ductus Arteriosus, Surgery 5 1 : 277, 1962.