Original article
Pediatric cardiac
Ascending Sliding Arch Aortoplasty: A Novel Technique for Repair of Arch Hypoplasia

https://doi.org/10.1016/j.athoracsur.2010.10.038Get rights and content

Background

Coarctation of the aorta (CoA) is often associated with clinically significant hypoplasia of the aortic arch. Historically, patch aortoplasty or bypass procedures have been the preferred techniques when arch augmentation is required in children beyond infancy. While safe and effective, these approaches require prosthetic or biologic material without the potential for growth, or normal endothelial and physiologic elastic function. This retrospective study reviews the use of a novel technique, ascending sliding arch aortoplasty, that utilizes viable autologous tissue for repair of arch obstruction in children beyond infancy.

Methods

Between April 2002 and January 2007, 8 patients ranging in age from 18 months to 15 years underwent repair of CoA with arch hypoplasia using ascending sliding arch aortoplasty. All patients were approached through median sternotomy, utilizing cardiopulmonary bypass and selective antegrade cerebral perfusion.

Results

There was no mortality or major morbidity. One toddler had pneumonia, resulting in an increased length of stay. Median duration of hospitalization was 5.8 days, ranging from 3 to 10 days. No patient had evidence of residual obstruction or recurrent CoA at a mean follow-up interval of 36 months.

Conclusions

Ascending sliding arch aortoplasty for CoA with arch obstruction in children beyond infancy is a safe technique that can be accomplished without deep hypothermic circulatory arrest. There is no evidence of recurrence at midterm follow-up. Because the augmentation is accomplished with viable autologous aortic tissue, the potential for growth, preserved elasticity and endothelial function, and resistance to infection make this method attractive for use in the young.

Section snippets

Patient Population

After Institutional Review Board approval and a waiver of consent, a retrospective review of medical records and the department clinical database identified 8 children, median age of 8.5 years (range 1.5 to 15.7), who had undergone surgical repair of arch obstruction utilizing ASAA. Interestingly, all 8 patients were male, which is consistent with the striking male-to-female ratio of nearly 70% seen with CoA [6]. Three patients had persistent obstruction at the level of the arch after various

Operative Data and Morbidity

Mean CPB time was 157 ± 19 minutes, and mean aortic cross-clamp time was 77 ± 29 minutes. Mean SCP time was 42 ± 10 minutes, and a brief period of circulatory arrest was necessary in 2 patients, 3 and 5 minutes, respectively, to finalize the anastomosis and to remove air from the aortic lumen. The lowest recorded mean cerebral oxygen saturation during SCP as determined by near-infrared spectroscopy was 92% ± 3%. Median hospital length of stay was 5.5 days (range 3 to 10). There has been no

Comment

Coarctation of the aorta is frequently associated with hypoplasia of the aortic arch. The clinical relevance of various degrees of arch hypoplasia in growing children is controversial and is confounded further by the difficulty in accurately assessing arch obstruction in the presence of juxtaductal CoA. The hypoplastic arch is frequently elongated, adding to the resistance to blood flow; however, elongation is difficult to quantify, and normal standards beyond the neonatal period are not well

References (32)

Cited by (17)

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    After restoration of full flow, reperfusion of the heart, rewarming, and separation from CPB is accomplished. Our experience with both the AAA and ascending sliding arch aortoplasty have been previously published.4,5 Our experience with the AAA spanned 17 years and included 275 patients with a perioperative mortality of 3% (eight patients) and in most of those patients the mortality could not be attributed just to the procedure but other pre-existing factors, such as syndromes, complex single ventricle repair, preoperative shock, prematurity, and complex biventricular repair.

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    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.2 This report included 8 patients aged 18 months to 15 years, of which 3 had prior procedures for aortic coarctation.

  • Clinical Assessment of Perfusion Techniques During Surgical Repair of Coarctation of Aorta With Aortic Arch Hypoplasia in Neonates: A Pilot Prospective Randomized Study

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    A cold Custodiol cardioplegic solution (Dr Kohler Pharma, Alsbach-Hahnlein, Germany) was administered antegrade for myocardial protection. We routinely used one of the following aortic arch reconstruction techniques: end-to-side anastomosis, extended end-to-end anastomosis either with or without arch plasty with foreign patch material (homograft patch or glutaraldehyde-treated autologous pericardium), and ascending aortic “sliding” procedure (both the descending and ascending aortas are anastomosed with the aortic arch9). After initiation of CPB, the ductus arteriosus was ligated and transected as the body temperature of the patient was cooled to 18–20°C.

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