Muscle-sparing aortic coarctation repair

Abstract

Objective: Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy.

Methods: We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically.

Results: Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found.

Conclusions: Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.

Keywords: children; coarctation of the aorta; muscle-sparing approach.

The latissimus dorsi (∗) has been mobilized and preserved, and the tip of the scapula is retracted cephalad. The intercostal space is entered by separating the periosteum is separated from the superior border of the fifth rib (white arrows) without dividing any intercostal muscles.

Figure 1

A, Position of the patient before surgery. The dashed line marks the spine. The solid line shows the tip of the scapula. B, Subscapular incision of 5 cm, 1 cm under the medial border of the scapula. C, The latissimus dorsi (∗) has been mobilized and preserved, and the tip of the scapula is retracted cephalad. The intercostal space is entered by separating the periosteum is separated from the superior border of the fifth rib (white arrows) without dividing any intercostal muscles. D, Reconstruction of the intercostal space. The periostium is sutured using a running suture to the rib.

Figure 2

The position of the coarctation of the aorta in the chest. The solid line under the scapula shows the incision location.

Figure 3

Neonatal ductus-dependent coarctation of the aorta with an elongated and hypoplastic distal arch (between the left common carotid and the left subclavian arteries), a stenotic isthmus, and a ductus arteriosus extending into the descending aorta.

Figure 4

Clamping of the aortic arch between the brachiocephalic trunk and the common left carotid artery. The left subclavian and the left common carotid arteries are clamped by hand-held clips. The ductus arteriosus is ligated and divided. The coarctation is resected. The underside of the aortic arch is fileted open, and a counterincision is made in the opposing proximal descending aorta to allow an extended end-to-end anastomosis.

Figure 5

The distal aortic arch and the proximal descending aorta are anastomosed with a running 7-0 or 6-0 polydioxanone suture.

Figure 6

Kaplan–Meier estimates of freedom from reintervention up to 14 years.