COARCTATION REPAIR USING END-TO-SIDE ANASTOMOSIS OF DESCENDING AORTA TO PROXIMAL AORTIC-ARCH

Background. Recurrent aortic coarctation after primary operative repai r in the neonate and small infant is seen most commonly within the fir st year of life. Inadequate removal of ductal tissue, failure to addre ss hypoplasia of the aortic arch, and suture line tension have been ci ted as important factors in early recurrence. Methods. To address thes e issues, we have used a technique of coarctation resection and extend ed anastomosis of the descending aorta to the undersurface of the aort ic arch. The salient features of this approach include extensive mobil ization of the aortic arch and neck vessels, careful trimming of all d uctal tissue, ligation of the isthmus just beyond the left subclavian artery, and end-to-side anastomosis of the descending aorta to a separ ate incision in the undersurface of the aortic arch proximal to all tu bular hypoplasia. Between July 1992 and January 1995, 19 consecutive n eonates (median age, 13 days) and 4 consecutive infants under 3 months of age (median age, 69 days) with a mean peak systolic upper to lower extremity resting gradient of 27.9 +/- 16.9 mm Hg underwent repair of aortic coarctation and tubular hypoplasia of the arch. Other procedur es performed at the time of repair included ligation of a patent ductu s arteriosus (n = 19), pulmonary artery banding (n = 3), and closure o f ventricular septal or atrial septal defect (n = 3). Results. There w ere no perioperative deaths. Early postoperative complications include d a recurrent laryngeal nerve injury and a transient focal tonic cloni c seizure. There was one late death, after a subsequent intracardiac s urgical procedure, at a median follow-up of 16 months (range, 1 to 29 months). Twenty-one of 22 late survivors were free of recurrent aortic coarctation by echocardiography findings and clinical examination, wi th a median upper to lower extremity gradient of 0 mm Hg. Reinterventi on for recurrent aortic coarctation was not required in any survivor. Conclusions. The technique described herein completely removes all pot entially abnormal tissue from the aorta, including ductal tissue and a ll tubular hypoplastic tissue proximal to the coarctation site.