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.

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.

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.

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.

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.

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.

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.

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.

Primary percutaneous coronary intervention in a patient with right internal mammary artery graft originating from arteria lusoria dextra.

INTRODUCTION: Congenital aomalies of the aortic arch, although numerous and heterogeneous, occur in less than 1% of individuals at autopsies. Left aortic arch with an aberrant right subclavian artery, also called arteria lusoria dextra, is the most common anomaly of the aortic arch, occurring in 0.5-2.5% of individuals. CASE OUTLINE: We report the case of a 48-year-old man suffering from acute inferoposterior-wall ST elevation myocardial infarction successfully treated by primary percutaneous coronary intervention.Ten years ago, the patient had undergone coronary artery bypass graft surgery with the implantation of two arterial grafts- left and right internal mammary arteries on both left anterior descending and right coronary artery. After several attempts to canulate truncus brachiocephalicus, angiogram revealed the left aortic arch with the aberrant right subclavian artery. To our knowledge, this is the first described case of primary percutaneous coronary intervention via the aberrant right subclavian artery and right internal mammary artery graft with stent implantation in the infarct related lesion of the distal segment of right coronary artery. Subsequent 64-multidetector computed tomography confirmed the angiographic findings. CONCLUSION: Early recognition of congenital anomalies of the aortic arch and its great vessels, even before coronary artery bypass graft surgery, could be crucial for the urgent and successful treatment of patients with life-threatening conditions, such as ST segment elevation myocardial infarction.

Supraclavicular artery island flap (SCAIF) vs free fasciocutaneous flaps for head and neck reconstruction.

OBJECTIVE: At our institution, the supraclavicular artery island flap (SCAIF) has become a reliable option for fasciocutaneous coverage of complex head and neck (H&N) defects. We directly compare the outcomes of reconstructions performed with SCAIFs and free fasciocutaneous flaps (FFFs), which have not been reported previously. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: Retrospective review of consecutive single-surgeon H&N reconstructions using fasciocutaneous flaps over 5 years. Reconstructions were divided into 2 groups: SCAIFs and FFFs. Patient demographics, surgical parameters, and outcomes were compared statistically between groups. RESULTS: Thirty-four flaps were used in H&N reconstruction (18 SCAIFs and 16 FFFs). There was no difference in patient demographics, distribution of defects, or follow-up (SCAIF 9.2 vs FFF 15.13 months, P = .65) between the 2 groups. The SCAIFs were larger than the FFFs (164.6 ± 60 vs 111 ± 68 cm(2), P < .05) and had shorter total operative times (588 ± 131 vs 816 ± 149 minutes, P < .05). Intensive care unit (ICU) length of stay was shorter for the SCAIF vs the FFF group (1.8 vs 5.6 days, P < .05). Overall morbidity was not significantly different (SCAIF 39% vs FFF 44%, P = NS). CONCLUSION: The SCAIF is a technically simpler and equally reliable sensate fasciocutaneous flap for H&N reconstruction with comparable outcomes, shorter operative time, less ICU stay, and no need for postoperative monitoring when compared with using FFFs. It should be considered a first-choice reconstructive option for complex H&N defects.

The supraclavicular artery island flap (SCAIF) for head and neck reconstruction: surgical technique and refinements.

OBJECTIVE: We have found the supraclavicular artery island flap (SCAIF) to be a reliable, first-line tool for the reconstruction of complex head and neck defects. Here, we review our technique of flap elevation and summarize the current literature citing important contributions in the evolution of this flap. DATA SOURCES: Medline literature review of supraclavicular artery island flap or shoulder flap in head and neck reconstruction with particular emphasis on developments within the past 5 years. REVIEW METHODS: Literature review of technique, indications, anatomy, modification, and outcomes of the supraclavicular artery island flap. CONCLUSION: The supraclavicular artery island flap is an important and reliable option in head and neck reconstruction. We use the flap routinely in our practice as a first-line technique when fasciocutaneous soft-tissue reconstruction is required, and we provide a detailed summary of the flap elevation and inset. IMPLICATIONS FOR PRACTICE: The supraclavicular artery island flap is a safe, reliable, technically simple, sensate, thin, pliable fasciocutaneous regional flap option that has low morbidity. It provides sensate, single-stage reconstruction for a variety of head and neck defects and should be considered as a first-line option in head and neck reconstruction.

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.

[A woman with palpitations and dysphagia]. / Een vrouw met palpitaties en passageklachten.

A 55-year-old female experienced palpitations and thoracic pain. Coronary angiography showed a right sided aorta. The patient was diagnosed with a Kommerell's diverticulum that compressed the esophagus and trachea. During follow-up she developed dysphagia and she underwent a transposition of the left subclavian artery to the left common carotid artery followed by endovascular treatment of the distal aortic arch and thereby excluding the diverticulum.

Aortic arch reconstruction for interrupted aortic arch using an aberrant right subclavian artery.

An aberrant right subclavian artery can be used in a variety of ways in complex aortic arch reconstructions, including reconstruction of an interrupted aortic arch. Here, we described the case of a 4-month-old female infant with a type B interrupted aortic arch, who underwent arch reconstruction using an aberrant right subclavian artery.

Percutaneous aortic valve replacement using a subclavian artery graft.

Over the past few years transcatheter heart valve implantation (THI) has become an alternative treatment for aortic valve replacement. The THI does not require a midline sternotomy or cardiopulmonary bypass and can be performed through a transfemoral or a transapical approach. In case of severe peripheral vascular disease the transapical route is usually chosen. However, when the use of a small anterolateral thoracotomy is not preferred due to comorbidities, the subclavian artery can be considered as a third alternative route. This case report describes an approach for THI through the subclavian artery, by using a Dacron graft.

Primary resection of Kommerell diverticulum and left subclavian artery transfer.

BACKGROUND: A Kommerell diverticulum (KD) is an aneurysmal remnant of the dorsal fourth aortic arch. This can be an independent cause of tracheoesophageal compression. We previously reported resection of the KD with left subclavian artery transfer to the left carotid artery for recurrent symptoms in patients with a right aortic arch, left ligamentum, and retroesophageal left subclavian artery after prior ligamentum division. In 2001 we began resecting the KD and transferring the left subclavian artery to the left carotid artery in selected patients as a primary operation. METHODS: From 2001 to 2011, 20 patients have had primary excision of a Kommerell diverticulum. Diagnosis was with computed tomographic scan (n = 14) or magnetic resonance imaging (n = 6) and bronchoscopy. Sixteen patients had a right aortic arch and 4 had a double aortic arch (right arch dominant). All patients were approached through a left thoracotomy. Fifteen patients had simultaneous division and reimplantation of the left subclavian artery into the left carotid artery. RESULTS: Mean age at operation was 9.1 ± 6.5 years (range 1.5 to 29.1 years). Symptoms included cough, wheezing, stridor, dysphagia, and dyspnea on exertion. Selection criteria included KD greater than 1.5 times the size of the left subclavian artery and posterior pulsatile compression of the trachea on bronchoscopy. There were no complications related to subclavian artery transfer. No patient required a blood transfusion. No patient had a recurrent laryngeal nerve injury or chylothorax. The mean hospital stay was 4.3 ± 2.5 days. All patients had resolution of their preoperative airway and esophageal symptoms. CONCLUSIONS: In selected patients with a vascular ring we now recommend resection of the associated Kommerell diverticulum and transfer of the retroesophageal left subclavian artery to the left carotid artery as a primary procedure. This strategy requires comprehensive and precise preoperative imaging with either computed tomography or magnetic resonance imaging.

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.