Andersons pediatric cardiology 1216

intervention,andcomplexityoftheanatomy.
Generally,earlierdebatehasgivenwaytoapreferenceinmostcentersfor
performingsurgeryatorshortlyafterpresentationatanyage.Thisissupported
byalowerincidenceoflatehypertensionwhenrepairisundertakenearly.There
havebeenreportsofahigherincidenceofrecoarctationwithearlierrepair,but
withadvancesintechnique,manylargestudiesshowanacceptablerateof
recurrenceevenwithneonatalrepair.
Similarly,forinterruptedaorticarch,mostpatientsshouldbemedically
stabilizedbeforebeingtakentotheoperatingroomfordefinitiverepairwithin
severaldaysoftheirpresentation.Althoughtheseinfantsareseldomoperatedon
electively,thereisrarelyaneedtorushapatienttotheoperatingroombefore
correctionofthenumerousmetabolicabnormalitiesthatoccurastheductus
closesunlessthepatientdoesnotrespondtoprostaglandintreatment.Inadults
foundtohaveinterruptedaorticarch,itispreferabletorepairthearchunlessthe
patientelectsformedicalmanagement.40


StrategiesforSurgicalTreatment
SurgicalManagementofSimpleCoarctation
ResectionandEnd-to-EndRepair
TheeraofcoarctationrepairstartedduringtheSecondWorldWar,whenBlalock
performedthefirstexperimentalrepairsusingtheturned-downleftsubclavian
arterytechnique.89Gross,inBoston,hadalsodemonstratedexperimentallythat
resectionwithend-to-endanastomosiswasfeasible.90Thefirstend-to-end
coarctationrepairincludingresectionwasperformedbyCrafoordin
Stockholm.91
Aslightmodificationofthisoriginaltechnique,theextendedend-to-end
repair,isthemostcommonlypracticedtechniquecurrently.Afterexcisionofthe
coarctation,anincisionontheaorticarchisextendedproximallyonthe
undersideofthearchtounderneaththecarotidostiaandamatchingincisionon
thedistalaortaiscompletedlaterallysothatitcanslideunderthedistalarch.

Thistechniquehasconsistentlyexcellentoutcomeswithlowmortalityandalow
incidenceofrecoarctationoraneurysmformation.Thisrepaircanaddressdistal
archhypoplasiabetweentheleftcarotidandleftsubclavianarteriesaswell.
Modificationsofthetechniquehavebeensuggested,includingthecombination
ofresectionandend-to-endrepairwithasubclavianflapangioplasty.Recent
reportssuggestthistobeasafetechniquewhenusedininfants,producingno
mortalityandverygoodresolutionofthegradients.92
Thereareasyetnoproperrandomizedcontrolledtrialscomparingthemany
techniquesusedforsurgicalrepair.Becauseofthis,retrospectivestudiesare
usedtoprovidetheevidencerequiredtoguideoptimaltreatment.Moststudies
seemtofindalowerincidenceofrecoarctationandaneurysmformationafter
someformofend-to-endanastomosis.93

LeftSubclavianPatchAortoplasty
Initialreportsofahighincidenceofrecoarctationwithend-to-endrepairin
infants,probablysecondarytoleavingresidualductaltissue,causedsurgeonsto
developstillotherapproaches.Theconceptionoftheleftsubclavianpatch
aortoplastybyWaldhausenandNahrwoldin1966eliminatedtheconcernofthe


circumferentialanastomosiswithend-to-endanastomosisandtheobstruction
causedbyearlyuseofinterpositiongrafts.94Ithasundergonemodificationsince
itsintroductiontoimproveresultsandisnotwidelypracticed,butitisusedby
manyforcertainsituationssuchasextremelowbirthweight,inabilityto
mobilizetheaortawell,andtheneedtominimizeclamptime.Thistechnique
(Fig.45.19)consistsofmobilizationofthesubclavianarterythroughastandard
leftthoracotomyandligationofthesubclavianarteryatitsfirstbranch.Care
shouldbetakentopreservethethyrocervicaltrunkandtheinternalthoracic
arteryinordertoimproveperfusiontotheleftarm.95Thevertebralarteryshould
beligatedtopreventsubsequentsubclaviansteal,leadingtocerebralischemia.

Thereportedbenefitsofusingthistechniqueoverothersincludetheuseof
exclusivelynativematerial,withaconsequentdecreasedriskofinfection,and
improvedpotentialforgrowth,95nocircumferentialanastomosis,lessextensive
dissection,andlesstensiononthesuturelinescomparedwiththeend-to-end
repair.

FIG.45.19 Subclavianflapaortoplasty.Thedottedlinesshowthesiteof
initialsurgicalincisionsintothenarrowedarterialpathways.

Theobviousdisadvantageisthelossofthemainarterialsupplytotheleft
arm,anddeleteriouseffectsongrowthofthearmhavebeenreported.These
rangefrommilddiscrepancyinlengthofthearm,similartothatfollowinga
Blalock-Taussigshunt,torarereportsofgangrene.96–98Attemptshavebeen
madetoaddressthelossofthesubclavianarteryusingtechniquesinvolving
reimplantation99,100oruseoftheinternalthoracicarterytopreservethearterial
supplytothearm.101Aneurysmshavealsobeendescribed102butareless