Aortic coarctation surgery


 * Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S.[mailto:psingh@perfuse.org], ; Assistant Editor(s)-In-Chief: Kristin Feeney, B.S.[mailto:kfeeney@perfuse.org]

Overview
The treatment choice depends on the patients age of presentation, severity, the location of the coarctation and other associated anomalies. For children who present early, the role of medical management is for stablizing the patient for surgery. However, in older kids and adolescent presenting with hypertension treatment is guided towards correction of hypertension and other associated anomalies. Therapy/Treatment is conservative if asymptomatic, but may require surgical resection of the narrow segment if there is arterial hypertension. The first operations to treat coarctation were carried out by Clarence Crafoord in Sweden in 1944. In some cases angioplasty can be performed to dilate the narrowed artery. If the coarctation is left untreated, arterial hypertension may become permanent due to irreversible changes in some organs (such as the kidney

General considerations for surgery

 * Indications for surgery: Significant hypertension, congestive heart failure (CHF)
 * Techniques available - Surgical relief of obstruction, balloon angioplasty and stents
 * Symptomatic neonates and infants should undergo urgent intervention soon after the infant is stabilized.
 * Asymptomatic patients - Undergo elective procedure
 * Elective surgical or balloon therapy in children aged 2-5 years is suggested.
 * There is lack of consensus about the best age for surgery and large randomized clinical trials are required in this direction. The rationale behind 2-5 years is that it gives aorta time to grow and to be larger than half the anticipated adult size at operation. However, issues of hypertension, left ventricle hypertrophy, and left venticular dysfunction favors earlier repair.
 * Delaying surgery beyond 5 years is not advisable as residual hypertension stays if intervention is performed after age 5 years.
 * The current surgical strategies are to aggressively and completely repair the coarctation of aorta and all other associated lesions
 * The mortality risk is high in neonates (surgery performed within 1 week of life), with associated cardiac anomalies, and low weight babies. This may be due to the poor presentation these infants have compared to the older child.
 * Pseudo-coarctation (abnormal tortuosity of the aorta) does not require surgery as the tortuosity doesn't result in significant obstruction or hypertension.

Surgical techniques

 * The choice of technique depends on the patient's age at presentation, size, associated abnormalities, and anatomy of the coarctation.
 * Surgical approach - median sternotomy is preferred over left lateral thoracotomy, in complex arch repairs.
 * Subclavian flap aortoplasty is found to be the most commonly performed followed by resection in end-to-end anastomosis, patch aortoplasty, and bypass graft when the surgery is done during infancy. Whereas, in children and adolescent undergoing coarctation repair end-to-end anastomosis is commonest followed patch aortoplasty and subclavian flap aortoplasty.
 * Patch aortoplasty are less frequently used these days because of concerns regarding the development of aortic aneurysm at the site of surgery,.
 * Available techniques:
 * Resection and end-to-end anastomosis,
 * Patch aortoplasty,
 * Left subclavian flap aortoplasty
 * Tubular bypass grafts
 * Combination techniques

Indications for surgery

 * There is a lack of consensus for the indications and the time for surgery. Some groups of surgeon consider balloon angioplasty and stenting as the initial approach and reserving surgery for more complicated conditions or treatment failures. Whereas, others consider surgical repair as the first line of therapy.
 * Surgery is the first choice in aortic coarctations involving:
 * Long length of aorta
 * Severe coarctations causing almost complete or complete obliteration of the aortic lumen.
 * Associated with other cardiac defects for e.g. large patent ductus arteriosus, ventricular septal defect.

Surgical complications

 * Recoarctation (commoner in infants compared to older children)
 * Aneurysms (associated with all repairs but commonest with prosthetic patch angioplasty) ,
 * Vascular complications (common with subclavian flap repair)
 * Paradoxical hypertension
 * Paraplegia ,