Anatomic Repair of Recurrent Aortic Arch Obstruction

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Anatomic Repair of Recurrent Aortic Arch Obstruction Carlos M. Mery, MD, MPH, Charles D. Fraser, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 17, Issue 4, Pages 271-279 (December 2012) DOI: 10.1053/j.optechstcvs.2012.10.002 Copyright © 2012 Terms and Conditions

Figure 1 A median sternotomy is performed. The ascending aorta, aortic arch, brachiocephalic vessels, and descending aorta are dissected as much as possible before instituting cardiopulmonary bypass. Particular attention must be taken to make every effort to preserve the left recurrent laryngeal nerve that will be traveling around the aortic arch. An appropriately sized Gore-Tex graft is sutured to the innominate artery and the arterial cannula is inserted into the graft. Bicaval cannulation is achieved and cardiopulmonary bypass is initiated. Further dissection is carried out as the patient is cooled to 18°C. Antegrade cardioplegia is administered into the aortic root after application of an aortic cross-clamp. A right atriotomy is performed and the left heart is vented through the atrial septum. Cardioplegia is repeated every 20 minutes via an antegrade cardioplegia catheter in the aortic root or a handheld device. The head vessels and descending aorta are controlled with tourniquets or clamps and a period of antegrade cerebral perfusion is started. a. = artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 2 Technique of aortic arch advancement. (A) The descending aorta is divided a few millimeters distal to the coarctation site. The proximal end is tied off just distal to the left subclavian artery. (B) A longitudinal incision is performed on the left aspect of the distal ascending aorta and proximal arch to correspond to the diameter of the descending aorta. (C) The descending aorta is brought forward and anastomosed to the ascending aorta using a continuous 6-0 or 7-0 Prolene suture. (D) The completed anastomosis. n. = nerve. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 3 Technique of ascending sliding arch aortoplasty. (A) The overall goal of this technique is to enlarge the coarctation site by sliding the ascending aorta posteriorly through a set of separate incisions. (B) The ascending aorta is divided just proximal to the innominate artery. The incision is performed in a slightly oblique fashion to include part of the undersurface of the aortic arch. (C) An incision is made on the undersurface of the arch extending from the prior incision to a few centimeters past the coarctation segment on the descending aorta. (D) A longitudinal incision is performed on the right aspect of the ascending aorta extending proximally from the cut edge for a few centimeters to enlarge the ascending aorta. (E) The corners of the ascending aorta are trimmed. (F) An anastomosis is performed between the ascending aorta and the incision encompassing the undersurface of the aortic arch and proximal descending aorta, with the apex of the ascending aorta corresponding to the apex of the descending aortic incision. (G) The completed anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 3 Technique of ascending sliding arch aortoplasty. (A) The overall goal of this technique is to enlarge the coarctation site by sliding the ascending aorta posteriorly through a set of separate incisions. (B) The ascending aorta is divided just proximal to the innominate artery. The incision is performed in a slightly oblique fashion to include part of the undersurface of the aortic arch. (C) An incision is made on the undersurface of the arch extending from the prior incision to a few centimeters past the coarctation segment on the descending aorta. (D) A longitudinal incision is performed on the right aspect of the ascending aorta extending proximally from the cut edge for a few centimeters to enlarge the ascending aorta. (E) The corners of the ascending aorta are trimmed. (F) An anastomosis is performed between the ascending aorta and the incision encompassing the undersurface of the aortic arch and proximal descending aorta, with the apex of the ascending aorta corresponding to the apex of the descending aortic incision. (G) The completed anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 3 Technique of ascending sliding arch aortoplasty. (A) The overall goal of this technique is to enlarge the coarctation site by sliding the ascending aorta posteriorly through a set of separate incisions. (B) The ascending aorta is divided just proximal to the innominate artery. The incision is performed in a slightly oblique fashion to include part of the undersurface of the aortic arch. (C) An incision is made on the undersurface of the arch extending from the prior incision to a few centimeters past the coarctation segment on the descending aorta. (D) A longitudinal incision is performed on the right aspect of the ascending aorta extending proximally from the cut edge for a few centimeters to enlarge the ascending aorta. (E) The corners of the ascending aorta are trimmed. (F) An anastomosis is performed between the ascending aorta and the incision encompassing the undersurface of the aortic arch and proximal descending aorta, with the apex of the ascending aorta corresponding to the apex of the descending aortic incision. (G) The completed anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 4 Technique of patch aortoplasty. (A) A longitudinal incision is created on the aortic arch and descending aorta encompassing a few millimeters on each side of the coarctation site. (B) A patch of glutaraldehyde-treated pericardium, Dacron, or Gore-Tex is used to enlarge the coarctation site. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions

Figure 5 Technique of interposition graft placement. (A) The aorta is divided proximal and distal to the coarctation segment, excising the segment. (B) An adequate cuff must be left proximally to allow suturing of the interposition graft. A Dacron graft is used for this technique. Operative Techniques in Thoracic and Cardiovascular Surgery 2012 17, 271-279DOI: (10.1053/j.optechstcvs.2012.10.002) Copyright © 2012 Terms and Conditions