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Children undergoing repair of aortic coarctation are at lifelong risk of developing recurrent aortic obstruction. Several surgical techniques have been described to address this challenging problem. Some centers have used extraanatomic aortic bypass techniques to avoid dissection on the previously operated field. We have favored a technique that relies on anatomic reconstruction. Although a repeat end-to-end anastomosis via a thoracotomy is possible in some cases, we have found that a strategy using a median sternotomy, cardiopulmonary bypass, and antegrade cerebral perfusion yields the best results. This technique allows for complete relief of obstruction and concomitant repair of intracardiac anomalies and limits the use of conduits in growing children.
Several different surgical techniques are used at Texas Children's Hospital for anatomic repair of recurrent aortic obstruction. These techniques (aortic arch advancement, ascending sliding arch aortoplasty, patch aortoplasty, and interposition graft plasty) are described in this article. The particular technique used is based on the age of the child, prior surgical interventions, the mobility of the aorta, and the anatomy of the defect.
All techniques involve a similar setup with median sternotomy, cardiopulmonary bypass, and antegrade cerebral perfusion (Fig. 1). Deep hypothermic circulatory arrest is kept at a minimum by suturing a graft to the innominate artery and providing antegrade cerebral perfusion during the aortic reconstruction.
Aortic Arch Advancement
The technique of aortic arch advancement is useful mainly for infants and toddlers that have an elastic enough aorta to allow translocation of the descending aorta into the distal ascending aorta/proximal arch without tension. Full dissection of the aorta as distal as possible allows for greater mobility (Fig. 2).
Ascending Sliding Arch Aortoplasty
The technique of ascending sliding arch aortoplasty involves enlarging the coarctation site by sliding the ascending aorta posteriorly. This technique is favored over aortic arch advancement in children beyond infancy to decrease tension in the anastomosis, as the elasticity of the aorta decreases with age (Fig. 3).
Patients with restricted mobility of the tissues precluding an arch advancement of the aorta or an ascending sliding arch aortoplasty or those with an extensive area of coarctation may benefit from patch enlargement of the coarctation site (Fig. 4).
Interposition Graft Placement
Placement of an interpositional graft is an alternative technique useful in cases with a long coarctation segment, particularly in patients who have previously undergone a subclavian flap procedure. This technique is avoided if possible in young children because it does not allow for growth of the conduit (Fig. 5).
Our group recently published the results of using anatomic techniques to repair recurrent aortic obstruction.
The report included 21 patients aged 7.8 ± 5.4 years (range, 0.2-15 years) with recurrent aortic arch obstruction. The procedure was performed via a thoracotomy in 2 patients; one underwent re-resection and end-to-end anastomosis and the other underwent a patch aortoplasty. The remaining 19 patients required a median sternotomy and cardiopulmonary bypass to perform aortic arch advancement (n = 10), patch aortoplasty (n = 8), or interposition grafting (n = 1). There was one perioperative death. No patients had required subsequent aortic interventions at 85 months postoperatively and only 2 patients had a 10 mm Hg arm-to-leg pressure gradient.
The technique of ascending sliding arch aortoplasty was recently described by our group.
This report included 8 patients aged 18 months to 15 years, of which 3 had prior procedures for aortic coarctation. There were no mortalities or major morbidities and no patient had recurrent or residual obstruction at 36 months' follow-up.
Anatomic repair of recurrent aortic obstruction can be safely performed using one of the techniques described in this article. Anatomic repair is almost always feasible for the treatment of recurrent obstruction even when the initial repair has included placement of an interposition graft. We have successfully treated patients with previous interposition grafts using the patch plasty technique or placed a new interposition graft in an anatomic position.
Although some recurrent obstructions may be repaired using an extended end-to-end anastomosis technique via a left thoracotomy, we have found that a median sternotomy with cardiopulmonary bypass allows an easier anatomic reconstruction with good results. Antegrade cerebral perfusion has allowed us to perform complex aortic reconstructions without the use of deep hypothermic circulatory arrest. The decision of which particular technique to use depends on the age of the patient, the anatomy of the obstruction, prior surgical interventions, and the elasticity of the tissue.
Anatomic reconstruction for recurrent aortic obstruction in infants and children.