Comparison of diameter and length of subclavian arteries to external jugular veins in variably sized dogs: A cadaveric study.

OBJECTIVE: To evaluate the length and diameter of a left external jugular vein graft as a substitute for the left subclavian artery in the modified Blalock-Thomas-Taussig shunt (mBTTS) in differently sized dogs. STUDY DESIGN: Cadaveric study. ANIMALS: Dog cadavers of three weight categories (10/group): <9.5 kg, 9.5 to 27 kg, and > 27 kg. METHODS: The length and infused external diameters of harvested vessels were measured with vernier calipers and recorded. A matched-pairs t test was used to test the difference in vessel lengths. The agreement in vessel diameters was assessed by using Lin's concordance correlation coefficient (CCC). Pearson's correlation coefficients (CC) were determined for vessel diameter to weight category and vessel length to weight category. RESULTS: The external jugular vein measured longer than the subclavian artery in all dogs (52.0 ± 20.8 mm and 23.0 ± 8.9 mm, respectively), with a mean difference of 28 ± 14.3 mm (P < .001). The mean external infused subclavian and external jugular diameters measured 7.8 ± 2.2 mm and 8.0 ± 2.5 mm, respectively (P = .32). Lin's CCC was 0.87. Pearson's CC were 0.74 in both vessel diameters (P < .001); they were 0.36 and 0.43, respectively, for subclavian artery and external juglar vein length (P < .001). CONCLUSION: Autologous external jugular vein grafts had an external diameter similar to subclavian artery and a significantly longer length in variably sized dogs. CLINICAL SIGNIFICANCE: External jugular vein grafts may be an acceptable graft choice for mBTTS.

Aortic arch augmentation using a pulmonary artery autograft patch and a reversed left subclavian artery flap for an interrupted aortic arch type B complex.

Adequate arch augmentation for interrupted aortic arch repair is quite important to avoid post-operative recoarctation and bronchial compression. We describe here two successful cases of aortic arch reconstruction using autologous materials such as a pulmonary artery patch and a reversed left subclavian artery flap in infants with an interrupted aortic arch type B complex.

Reverse subclavian flap repair and maintenance of antegrade blood flow within the left subclavian artery in neonates with aortic coarctation and distal arch hypoplasia.

Surgical palliation for aortic coarctation with aortic arch hypoplasia in neonates and infants has been used in the clinic as the most beneficial treatment for this disorder. This technique allows the correction of aortic coarctation by the use of "extended" anastomosis without cardiopulmonary bypass, which expands the hypoplastic distal aortic arch via the use of a reverse subclavian flap repair. This technique maintains antegrade blood flow within the left subclavian artery.

Subclavian flap aortoplasty and preservation of left upper extremity circulation using an interposition graft.

OBJECTIVES: To introduce a surgical technique to maintain left upper limb blood flow after subclavian flap aortoplasty (SFA). METHODS: Five patients (9 to 23 months of age) with a diagnosis of long-segment aortic coarctation underwent conventional SFA. A Gore-tex graft was interposed between the stump and the proximal descending aorta to maintain perfusion of subclavian artery. RESULTS: All patients had a patent Gore-tex graft and normal blood flow of the subclavian artery and left upper limb. One patient expired and four others were discharged with a mean follow-up of 48 months. On follow-up all patients had normal development of the left upper limb and no signs of limb ischemia. Echo findings revealed normal arch flow with normal flow in the Gore-tex graft and left upper extremity. CONCLUSIONS: Interposing a Gore-tex graft between the subclavian artery stump and proximal descending aorta concomitant with SFA can be safely performed in infants with long-segment aortic coarctation, with preservation of left upper extremity circulation.

Sirolimus-eluting stent fracture and aneurysm formation in a young child with a coronary artery bypass graft.

Clinical experience with coronary stent implantation in children is very limited. In-stent restenosis, thrombosis, and aneurysm formation are known complications. Recently, fracture of a drug-eluting stent was reported to be a cause of in-stent restenosis, but the natural course of stent fracture and proper management options remain uncertain. This report describes the case of a 7-year-old boy with a sirolimus-eluting stent implanted to treat stenosis of a coronary artery bypass graft who showed complete stent fracture and aneurysm formation. During the 2-year follow-up period, the boy experienced complete regression of the aneurysm without in-stent restenosis.

Subclavian flap aortoplasty for infant coarctation of the aorta

Aortic resection with an extended end-to-end anastomosis is the surgical gold standard treatment for infant aortic coarctation and has excellent early and long-term outcomes.  Subclavian flap aortoplasty is an alternative surgical technique that offers some advantages because there is no need to do extensive dissection and mobilization of the aortic arch and descending aorta as required in an extended end-to-end anastomosis.  This video tutorial illustrates the technical aspects of subclavian flap aortoplasty in an infant.

Subclavian artery pseudoaneurysm long after the division of modified Blalock-Taussig shunt.

A massive but asymptomatic left subclavian artery pseudoaneurysm was diagnosed in a 30-year-old female patient with transposition of the great arteries, ventricular septal defect, and pulmonary atresia. After undergoing bilateral modified Blalock-Taussig shunts at the age of 4 months and 3 years, respectively, she underwent the Rastelli operation and division of both shunts at the age of 6 years of age. The pseudoaneurysm was not discovered at the follow-up investigation at age 14. During the time period from age 18 to 30 years, she was lost to follow-up, she was confirmed to be free from infectious disease, traumatic accident, or vasculitis. Pregnancy-induced hypertension was not associated during her pregnancy. Graft replacement of the left subclavian artery and redo right ventricular outflow tract reconstruction were successfully performed under deep hypothermic circulatory arrest at the age of 33 years.

A modification of extended aortic arch anastomosis augmented with subclavian flap aortoplasty for interrupted or hypoplastic aortic arch.

BACKGROUND: Surgical repair for hypoplastic aortic arch in neonates carries a substantial risk of recurrent obstruction. Simple arch anastomosis is not always a solution in cases of extended arch hypoplasia. We present our modified technique of extended aortic arch anastomosis augmented with subclavian flap aortoplasty. METHOD: We describe two neonates: interrupted aortic arch and transverse arch hypoplasia associated with aortic coarctation, who underwent a modification of extended aortic arch anastomosis augmented with subclavian flap aortoplasty. RESULTS: The patients recovered without any pressure gradient at the anastomotic site. Postoperative aortography showed no arch obstruction and they successfully underwent second stage repair. CONCLUSION: Our technique provides extensive augmentation of the aortic arch with a tension-free, wide and non-circumferential suture line which preserves potential for growth. The technique described may avoid persistent or repeat arch obstruction.

Severe and resistant hypertension in an older woman with claudication.

Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.

Augmentation of the Lesser Curvature With an Autologous Vascular Patch in Complex Aortic Coarctation and Interruption.

BACKGROUND: Reconstruction of the aortic arch in patients with complex aortic coarctation or interruption continues to be a challenge because of early left main bronchial compression or recoarctation and late Gothic arch formation. We propose a modified arch reconstruction technique augmenting the lesser curvature with an autologous vascular patch, which can relieve tension on the anastomosis without a prosthetic material. METHODS: We retrospectively reviewed 33 patients with coarctation and arch hypoplasia (n = 31) or arch interruption (n = 2) who underwent arch reconstruction with an autologous vascular patch from 2007 to 2012. Median age at the operation was 17 days (range, 5 to 200 days). Median body weight was 3.7 kg (range, 2.3 to 7.0 kg). Cardiopulmonary bypass was used for all operations. Median antegrade selective cerebral perfusion time was 35 minutes (range, 23 to 59 minutes). Combined intracardiac anomalies in 29 patients (88%) were corrected simultaneously. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from aortic isthmus (n = 25), pulmonary artery (n = 4), left subclavian artery (n = 2), aberrant right subclavian artery (n = 1), or distal arch (n = 1). RESULTS: One patient (3%) died of acute respiratory distress syndrome. All survivors were discharged at 15 days (range, 7 to 58 days) postoperatively without neurologic complications or bronchial obstructions. Median follow-up was 24.8 months (range, 0.2 to 48.5 months). No recoarctation was observed during follow-up, and no patient needed reoperation. CONCLUSIONS: Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in excellent midterm outcomes. Not only can a more natural shape of arch and less tension on the anastomosis be obtained, but complications, such as left main bronchial obstruction or recoarctation, can also be minimized. Long-term follow-up is needed to evaluate late development of recoarctation, hypertension, or aneurysm formation.

Left subclavian artery free graft as a salvage technique after failed coronary artery transfer in arterial switch operation.

Coronary artery transfer in transposition of the great arteries with single coronary artery or intramural coronary artery is still a technically demanding procedure. We present a technique of left coronary bypass using a free graft of left subclavian artery for the management of failed coronary artery transfer of left intramural coronary artery.

Reconstruction of left main coronary artery with subclavian artery free graft in an infant.

We report the case of a 3-month-old infant with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) with absent left main coronary artery (LMCA). She underwent repair by reimplantation technique with the construction of a short LMCA using two opposite flaps. Two months later she was re-admitted in cardiac failure. Occlusion of the reconstructed LMCA was found by angiogram. At reoperation the right subclavian artery was used as a free interposition graft to reconstruct the LMCA. The post-operative course was uneventful. At 8 months she was asymptomatic and LMCA patency was demonstrated by angiogram.

Arterial Switch Operation in Single Coronary Ostium With Intramural Course: Subclavian Artery Patch Angioplasty.

This report describes a neonatal arterial switch operation in a transposition of the great arteries with single ostium and intramural course coronary pattern. The technique proposed is based on the creation of two coronary neoostia by incising the left coronary intramural course and splitting the common button followed by a patch enlargement of left coronary button using the left subclavian artery.

Supraclavicular artery island flap in head and neck reconstruction.

Due to the complex anatomy of the head and neck, a wide range of pedicled or free flaps must be available to ensure optimal reconstruction of the various defects resulting from cancer surgery. The supraclavicular artery island flap is a fasciocutaneous flap harvested from the supraclavicular and deltoid regions. The blood supply of this flap is derived from the supraclavicular artery, a direct cutaneous branch of the transverse cervical artery in 93% of cases or the supraclavicular artery in 7% of cases. The supraclavicular artery is located in a triangle delineated by the posterior border of the sternocleidomastoid muscle medially, the external jugular vein posteriorly, and the median portion of the clavicle anteriorly. This pedicled flap is thin, malleable, and is easily and rapidly harvested with a reliable pedicle and minimal donor site morbidity. It can be used for one-step innervated reconstruction of many types of head and neck defects. It constitutes an alternative to local flaps, while providing equivalent functional results and must be an integral part of the cancer surgeon's therapeutic armamentarium.

Creating an arc-shaped aorta: use of the subclavian artery for interrupted aortic arch repair.

BACKGROUND: With interrupted aortic arch (IAA), a direct anastomosis may produce an angular-shaped aortic arch instead of the normal arc-shaped aorta, when the discontinuity is considerably long. That may lead to aortic stenosis and to compression of the pulmonary artery or the main bronchus. If a tube graft is used, reoperation for graft exchange is inevitable. We demonstrate the results of using the subclavian artery for creating an arc-shaped aorta in IAA repair. METHODS: Between February 2006 and October 2012, 23 patients underwent IAA repair using the subclavian artery. The subclavian artery was closed distally, divided, and longitudinally incised from the transected end to the aorta. This flap was used to bridge the gap of the IAA, by forming the posterior wall of a new aortic segment. The arch was completed using glutaraldehyde-fixed autologous pericardium (52%) or homograft (48%). RESULTS: Median follow-up time was 4.8 years (range, 1.3 to 6.9). There were no early deaths and 1 late death. On postoperative angiographic imaging, the aorta takes an arc-shaped course in all cases. Aortic arch stenosis developed in 7 patients (30%). Four patients were treated interventionally, and 3 surgically. During follow-up, there was no compression of the pulmonary artery or the main bronchus. CONCLUSIONS: By using the subclavian artery, an arc-shaped aorta can be accomplished without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might be not applicable to bridge a long interruption.

Influence of age at operation on late results with subclavian flap aortoplasty.

Despite the popularity of subclavian flap aortoplasty for repair of aortic coarctation, reported experience and follow-up in neonates is surprisingly limited. This paucity of reports prompted this review of age-related late recurrence rates. Of 83 patients having subclavian flap aortoplasty from 1976 to 1983, 60 were less than 8 weeks of age at operation (mean 2.6 weeks). Operative and late mortality were 18% and 14%, respectively. After a mean follow-up of 26 months, 10 patients have experienced recurrent coarctation (a mean of 10 months elapsed between operations). For 23 patients older than 8 weeks of age at operation (mean 20 months), operative and late mortality were 13% and 10%, mean follow-up is 16 months, and no patient has yet experienced recurrence. Thus, 75% of infants less than 8 weeks of age at operation are free of recoarctation at 2 years, and 100% of older children are free of recoarctation at 2 years (p = 0.06). Review of the literature corroborates our findings. The difference in recurrence rates may be due to age-dependent involution of residual coarctation tissue unavoidably left in place during subclavian flap aortoplasty. We conclude that subclavian flap aortoplasty is effective for correction of coarctation in infants, but patients less than 8 weeks old have a significant risk of early recurrence. Based on this review and our recently reviewed experience with end-to-end anastomosis, our preference is to use the latter in this age group when technically feasible.

Subclavian flap repair of coarctation of the aorta in neonates. Realization of growth potential?

The subclavian flap repair for coarctation of the aorta allows potential for growth by utilizing autogenous tissue. Although well documented in young children, its promise in the tiny neonate warrants further evaluation. Since August, 1979, 29 patients, including 24 infants, have undergone subclavian flap repair at the University of Maryland Hospital. Weights ranged from 1.4 to 5 kg (mean 3.2 kg). All patients less than 6 months old had associated intracardiac defects and were in severe congestive failure. Fifteen responded to preoperative prostaglandin infusions. The overall early mortality was 14%; among the neonates it was 21%; and among those operated upon within the first week of life, 33%. There was one intraoperative death among the eight patients who underwent simultaneous pulmonary artery banding. There were no deaths among patients older than 5 days at operation. Four of the five neonates who died had some variant of hypoplastic left heart syndrome, with severe stenosis or atresia of the systemic atrioventricular valve, critical aortic stenosis, or hypoplastic left ventricle. Twenty-two survivors continue to do well up to 3.7 years postoperatively (mean follow-up 26 months). At follow-up all patients are normotensive with brisk lower extremity pulses. Patients now weigh 1.3 to 6.9 (mean 2.3) times their operative weight, and only one patient has a measured arm-to-leg gradient greater than 10 mm Hg (mean gradient 3.7 mm Hg). Seven of the neonates have undergone repeat catheterization, and all had satisfactory growth of the subclavian flap segment of repair and no gradient. Two older patients (3 and 4 years old at operation) have undergone exercise testing 3.7 years after repair, with peak exercise gradients of only 7 and 15 mm Hg. We therefore continue to utilize this technique for the treatment of coarctation even in tiny neonates.

Surgical treatment of anomalous origin of the left coronary artery in infancy and childhood. Early and late results in 20 consecutive cases.

From 1972 to September, 1979, 20 patients underwent transplantation of the anomalous left coronary artery to the aorta, either directly or via a graft. Correction of ischemia-induced mitral insufficiency was associated in eight patients and a postinfarction left ventricular scar was excised in 12. Operative mortality was high among patients under 1 year of age (4/5). Among older children it was 15%. There were not late deaths among patients surviving the operation (mean follow-up 3 years). All but one had marked clinical improvement and reduction of cardiomegaly. Eleven patients underwent angiographic control, with a patent graft or anastomosis demonstrated in every case. Operation is advocated for patients over 1 year of age. The best treatment of symptomatic infants remains controversial.

Determinants of early success in repair of aortic coarctation in infants.

Fifty-five infants less than 1 year of age underwent repair of coarctation of the aorta between 1967 and 1981. Sixteen (29%) died while in the hospital, with one death occurring from "pure" coarctation. Of the remaining patients, four among 20 with associated ventricular septal defect (VSD) and 11 among 19 with other major associated cardiac anomalies (p = 0.002) also died. Thirteen (62%) of 21 patients treated by resection and end-to-end anastomosis died in the hospital, while only two (7%) of 30 in whom the subclavian flap repair was used died (p less than 0.0001). Good femoral pulses were present early postoperatively in 29 of 30 patients with the subclavian flap in whom observations were recorded and in nine of 12 patients who received end-to-end anastomosis (p = 0.06). Multivariate analysis showed only the very small size of the patient, the presence of major associated cardiac anomalies other than VSD, and nonuse of the subclavian flap method to be incremental risk factors for hospital death. These data and the reports of others show the subclavian flap technique to be the method of choice for repair of coarctation of the aorta in infants.