Subclavian flap angioplasty: Does the arch look after itself?

Objectives: We sought to assess the early and long-term results of subclavi an flap angioplasty in neonates and infants, with particular attention to g rowth of the hypoplastic arch. Methods: A retrospective analysis of 185 consecutive patients who underwent subclavian flap angioplasty between 1974 and 1998 was carried out. The pat ients included 125 neonates and 60 infants, with a median age of 18 days. S ixty-six (36%) patients had an additional ventricular septal defect, 41 (22 %) patients had aortic arch hypoplasia diagnosed preoperatively, 141 (76%) had an associated patent ductus arteriosus, and 41 (22%) had additional com plex heart disease. Follow-up was with transthoracic Doppler echocardiograp hy in all patients. Results: The early mortality was 3%. Recoarctation, defined as a Doppler gr adient of 25 mm Hg or more, occurred in 11 (6%) patients at a median follow -up of 6.2 years (6.2 +/- 4.6 years). This included 4 of the 41 patients in whom arch hypoplasia was diagnosed preoperatively, There were no complicat ions with the left arm, By multivariate analysis, risk factors for death we re determined to be residual arch hypoplasia and low birth weight. The only risk factor for recoarctation was persistent arch hypoplasia after surgica l treatment. However, angiographic imaging of the aorta showed that recoarc tation was not due to a hypoplastic transverse arch, and it was probably at the site of ductal tissue. Survival at 5 and 10 years was 98% and 96%, res pectively. Freedom from reoperation for recoarctation at 2 years was 95%, a nd at 5, 10, and 15 years, it was 92%, Conclusions: Subclavian flap repair remains an effective technique for repa ir of aortic coarctation with excellent results and low mortality, In the m ajority of patients, arch hypoplasia regresses after this procedure.