Original article: cardiovascular
Anatomic reconstruction for recurrent aortic obstruction in infants and children

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.
https://doi.org/10.1016/j.athoracsur.2004.02.126Get rights and content

Abstract

Background

Patients undergoing operative repair of aortic obstruction are at a lifelong risk of recurrent obstruction, and there is controversy regarding the optimal surgical technique. We have used an alternative strategy for recurrent aortic obstruction, typically involving anatomic reconstruction by means of a median sternotomy, and describe our techniques and results.

Methods

Twenty-one patients presented with recurrent aortic arch obstruction. Mean age and weight were 7.8 ± 5.4 years (range, 0.21 to 15.2 years) and 30.6 ± 21.8 kg (range, 3.6 to 90 kg), respectively. Recurrence involved the aortic arch to some degree in each case, as the mean preoperative transverse aortic arch z score was −2.9 ± 1.6 (range, −7.0 to 0.1). Thoracotomy was possible in 2 patients, using re-resection with end-to-end anastomosis (n = 1) and patch aortoplasty (n = 1). The remaining 19 patients required median sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest for complete relief of obstruction by aortic arch advancement (n = 10), patch aortoplasty (n = 8), or interposition grafting (n = 1).

Results

There was 1 hospital death. Invasive blood pressure monitoring revealed no residual arm-to-leg gradient in 19 patients and a 20-mm Hg gradient in 2 patients. There have been no late deaths. No patients have undergone subsequent aortic intervention, and all are asymptomatic up to 85 months postoperatively. Two patients are currently followed with a 10-mm Hg arm-to-leg blood pressure gradient.

Conclusions

Anatomic reconstruction for recurrent aortic obstruction can be safely accomplished in the majority of patients. We favor median sternotomy because of the ability of establishing cardiopulmonary bypass, the facility of anatomic reconstruction techniques, and the ability to repair concomitant cardiovascular lesions.

Section snippets

Material and methods

Since 1995, 21 patients have presented with recurrent aortic arch obstruction after previous repair, 17 boys and 4 girls. After approval from the local institutional review board, a retrospective chart review was conducted such that all preoperative, operative, and hospital course data were reviewed, and the most recent follow-up data were extracted from the cardiology clinic database. Preoperative echocardiograms and catheterization cineangiograms were reviewed by two cardiologists (G.C.K. and

Operative data

There were no intraoperative deaths. The ischemic times for patients undergoing thoracotomy were 15 and 24 minutes. Among patients undergoing median sternotomy, mean cardiopulmonary bypass time was 164.9 ± 70.0 minutes (range, 83 to 387 minutes) and mean aortic cross-clamp time was 90.4 ± 53.6 minutes (range, 53 to 291 minutes). Cumulative DHCA time averaged 27.4 ± 8.7 minutes (range, 14 to 50 minutes) in patients not undergoing RLFP and was 6 and 16 minutes in patients undergoing RLFP as an

Risk factors and pathogenesis for recurrent aortic obstruction

There has been much debate concerning the risk factors for recurrent aortic obstruction after repair of coarctation or interrupted aortic arch. Beekman and associates [12] found that the incidence of recurrence was 1.5% of 197 patients undergoing coarctation repair beyond 3 years of age and 38% of 42 patients undergoing repair in the first 3 months of life. In a recent review of 103 patients undergoing primary coarctation repair, younger age and smaller absolute transverse arch diameter were

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