Tutorial
Subclavian flap aortoplasty for infant coarctation of the aorta
Aortic resection with an extended end-to-end anastomosis is the surgical gold standard treatment for infant aortic coarctation and has excellent early and long-term outcomes. Subclavian flap aortoplasty is an alternative surgical technique that offers some advantages because there is no need to do extensive dissection and mobilization of the aortic arch and descending aorta as required in an extended end-to-end anastomosis.
This video tutorial illustrates the technical aspects of subclavian flap aortoplasty in an infant.
Subclavian flap aortoplasty (SFA) for aortic coarctation offers some advantages over the standard resection and extended end-to-end anastomosis (EEA). EEA is an established technique that offers excellent early and long-term outcomes . However, SFA does not require extensive dissection and mobilization of the aortic arch and descending aorta, as is the case with EEA.
In SFA, the left subclavian artery is sacrificed and used as a flap to enlarge the coarctated area. Technically, there are a few key factors that are crucial to the success of the procedure. First, accurate marking of the planned line of the vertical arteriotomy on the aortic isthmus and the subclavian artery is of the utmost importance in order to preclude the distortion of the flap after repair. Second, exposure and ligation of the branches of the subclavian artery are important to prevent subclavian steal syndrome.
In this tutorial, we demonstrate our technique for the surgical treatment of infant coarctation using SFA.
1 - Patient presentation (0:14)
A 35-day-old male infant was referred for surgical treatment of aortic coarctation. The patient was a full-term baby (3350 gr) with an uneventful prenatal and postnatal history. The diagnosis of aortic coarctation was made in another center during an evaluation for difficulty in suckling. Physical examination revealed a 35 mmHg systolic pressure difference between the upper and lower extremities. Transthoracic echocardiography revealed severe infantile type coarctation with isthmus hypoplasia (up to 48 mmHg peak gradient). The ductus arteriosus was seen to be closed. Subclavian flap aortoplasty was planned for treatment of the patient.
2 - Thoracotomy and surgical exposure (0:36)
To facilitate the anastomosis of the flap, a 7/0 Prolene approximation suture is placed between the midportion of the distal part of the flap and the lowest point of the arteriotomy. We start our anastomosis, using a 7/0 Prolene suture, from the base of the lateral border of the subclavian artery flap and advance it down to the level of the lowest part of the arteriotomy on the descending aorta. After completing the lateral side, the medial side of the anastomosis is performed in a similar fashion. It is not necessary to resect the intimal shelf.
When both sides have been completed the distal aortic clamp is removed, de-airing is done, and both sides are tied to each other. With appropriate fluid resuscitation, the proximal aortic clamp is removed.
The final appearance of the subclavian flap aortoplasty is satisfactory. The thoracotomy is closed in a standard fashion.
3 - Aortotomy and preparation of the left subclavian artery flap (3:00)
A posterolateral thoracotomy through the 3rd intercostal space is done via a skin incision of approximately 5 cm. The descending aorta, hypoplastic aortic isthmus, aortic arch up to the left common carotid artery, and left subclavian artery are dissected. There is no need to do extensive dissection and mobilization of the proximal and distal aortic segments.
The planned line of the arteriotomy for the subclavian flap aortoplasty is marked with 3 superficial 7/0 Prolene stitches placed at the descending aorta, isthmus, and left subclavian artery. The ductus arteriosus is then encircled and 2 circumferential double fixation stitches are placed to occlude the ductus. The branches of the left subclavian artery are then clipped.
4 - Anastomosis of the subclavian artery flap to the coarctated segment (4:19)
After clamping the descending aorta and the aortic arch distal to the left common carotid artery, the left subclavian artery is transected, just before its first branch. The arteriotomy, starting from the descending aorta 3 - 4 mm distal to the level of the ductal insertion site up to the left subclavian artery, is performed. It is important to follow the previously placed marking stitches during the arteriotomy.
The luminal diameter of the coarctated aortic isthmus is small so a great deal of care should be taken not to damage the posterior aortic wall with the tip of the scissors.
Outcome
Intraoperative pressure measurement reveals a satisfactory outcome. Postoperative control echocardiography shows a wide-open aortic isthmus with no residual pressure gradient.
Discussion
In many centers, SFA has been abandoned in favor of EEA due to initial studies showing higher rates of re-coarctation after SFA in the long term . The opponents of SFA have claimed that ductal tissue is often left in situ with SFA, and this has been implicated as the leading factor in the development of re-coarctation postoperatively. In addition, ischemic left arm injury after division of the left subclavian artery has caused concern and is another major disadvantage of the technique .
On the other hand, the proponents of SFA have claimed that the technique has some advantages, such as using autologous tissue with its potential for growth and achieving a tension-free repair with limited need for extensive dissection compared to EEA . Recently, the rate of re-coarctation and residual arterial hypertension after repair of coarctation of the aorta using SFA and EEA have been reported to be comparable at midterm follow-up .
Although each institution has its own routine and protocols for surgical repair of infant coarctation, SFA should be kept in the armamentarium of pediatric cardiac surgeons dealing with coarctation surgery.
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PubMed Abstract | EJCTS Full Text
None declared.
Authors
Koray Ak, Berna Saylan Cevik, Figen Akalin, Sinan Arsan, and Adnan Cobanoglu
Authors' Affiliation
Marmara University Faculty of Medicine
Department of Cardiovascular Surgery
Pediatric Cardiac Surgery
Istanbul, Turkey
Corresponding Author
Koray Ak, MD, PhD
Marmara University Faculty of Medicine
Department of Cardiovascular Surgery
Pediatric Cardiac Surgery
Istanbul, Turkey
Email: korayakmd@gmail.com
© The Author 2021. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
