title: Modification of the subclavian patch aortoplasty for repair of aortic coarctation in neonates and infants.
abstract: BACKGROUND
  Coarctation repair in neonates or small infants, using a subclavian patch, has a relatively high risk of restenosis, especially if complicated by the presence of a short subclavian artery or long coarctation segment. We introduce a technical modification that facilitates the use of a subclavian flap, and decreases the restenosis rate in this subgroup of patients. It consists of a side-to-side transverse aortic anastomosis at the level of the coarctation, which widens the coarctation segment, shortens the isthmus, and pulls the distal end of the aortotomy proximally, allowing a tension-free subclavian flap aortoplasty.
  
  
  METHODS
  Fifty-three consecutive neonates or infants less than 18 weeks old, with complex coarctation, underwent repair using this technique. Mean age was 26+/-3 days and 36 patients (68%) were less than 28 days old. Weights ranged from 1.4 to 6.4 kg (mean 3.4+/-0.2 kg), and 26 patients had other cardiac anomalies. Preoperative gradient by Doppler measurement ranged from 25 to 90 mm Hg (mean 49+/-2 mm Hg).
  
  
  RESULTS
  Mean aortic cross-clamp time was 27+/-1 minutes (range 19 to 34 minutes). There were no deaths or surgical complications. Follow-up echocardiogram 4 to 52 months postoperatively (mean 25+/-2 months) demonstrated no significant pressure gradient (less than 20 mm Hg) in 51 of 53 patients (96%), and a significant gradient in 2 patients (4%), which was subsequently corrected with balloon angioplasty.
  
  
  CONCLUSIONS
  The technical modification described shortens the isthmus, and thus allows for a longer aortotomy distal to the area of coarctation resulting in a tension-free repair especially in patients with a short subclavian artery. It also widens the area of coarctation, and as a result leads to a lower early recoarctation rate in this high-risk group. With increasing emphasis on the need for a longer aortotomy to prevent restenosis, this modification will have increasing application, especially in the neonatal population.
authors.affiliation: Division of Cardiothoracic Surgery, Heart Institute for Children, Hope Children's Hospital, Oak Lawn, Illinois, 60453, USA.
authors.forename: B S
authors.initials: BS
authors.lastname: Allen
authors.forename: A O
authors.initials: AO
authors.lastname: Halldorsson
authors.forename: M J
authors.initials: MJ
authors.lastname: Barth
authors.forename: M N
authors.initials: MN
authors.lastname: Ilbawi
mesh_terms: D001017:Aortic Coarctation / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007231:Infant, Newborn; D013524:Surgical Flaps; D014656:Vascular Surgical Procedures / Q000379:methods