Coarctation of aorta may be isolated or it may have other co-existing cardiac and vascular lesions. In critically ill neonates with coarctation, IV prostaglandin (PGE 1 at 0.1 mg/Kg/mt) is begun immediately and continued till operation is completed. This leads to re-opening of ductus and re-pcrfusion of Iower part of the body and disappearance of nletabolic acidosis.
When patient's condition is stabilized, operation is undertaken. Neonates and infants who are free ol synlptoms of heart failure are advised surgery at around 3-6 months. Previously it was though1 that deferring the operation until the child is bigger reduces the chances of re-coarctation. This conclusion is found to be incorrect. Coarctation co-existing with VSD in an infant with heart failure needs surgical con-ection. Choices available are repair of coarctation alone, coarctation repair with pulmonary artery banding
and repair of both through median sternotomy under deep hypothermia and circulatory arrest. In experienced centers, the latter method is the procedure of choice.
Coarctation presenting i11 an adult should be operated regardless of age.Persistent or recurrent coarctation aftel* previous surgery is best treated by balloon dilatation. Surgery for recoarclation carries slightly higher risk of paraplegia as the collaterals would have disappearecl and clamping of aorta for longer period can be dangerous.
Techniques of Operation
Resection aizd Primary End to End Annstomosis For neonates and infants the best operation is resection of coarctation and primary end-to-end anastomosis. With the baby in right lateral position a left posterolateral thoracotomy is done through Ihe fourth intercostal space. Lung is retracted anteriorly and mediastind pleura is incised over the aorta and coarctation upto the exit point of the subclavian artery. It is also incised for several centimeters on the dcscendiilg thoracic aorta. Multiple stay sutures are taken after raising mediastinal pleural flaps anteriorly and posteriorly.Dissection is done around subclavian artery, distal arch, coarctation and descending aorta. Ligamenturn arteriosus or ductus when present is dissected and ligated or sutured and divided. Clamp is applied on the proximal aorta including subclavian artery. Distally the clamp is applied on the descending tl~oracic aorta well below the coarcted segment. Intercostal vessels are ligated and divided if they are in the narrow part of post coarct segment. If they need not be sacrificed they are looped for haemostasis. The istl~inus and nairowed portions and coarctation segments are resected. End to end anastomosis is done with 6-0 or 7-0 absorbable sutures. Some surgeons prefer continuous sutures for posterior anastomotic line and interrupted
When patient's condition is stabilized, operation is undertaken. Neonates and infants who are free ol synlptoms of heart failure are advised surgery at around 3-6 months. Previously it was though1 that deferring the operation until the child is bigger reduces the chances of re-coarctation. This conclusion is found to be incorrect. Coarctation co-existing with VSD in an infant with heart failure needs surgical con-ection. Choices available are repair of coarctation alone, coarctation repair with pulmonary artery banding
and repair of both through median sternotomy under deep hypothermia and circulatory arrest. In experienced centers, the latter method is the procedure of choice.
Coarctation presenting i11 an adult should be operated regardless of age.Persistent or recurrent coarctation aftel* previous surgery is best treated by balloon dilatation. Surgery for recoarclation carries slightly higher risk of paraplegia as the collaterals would have disappearecl and clamping of aorta for longer period can be dangerous.
Techniques of Operation
Resection aizd Primary End to End Annstomosis For neonates and infants the best operation is resection of coarctation and primary end-to-end anastomosis. With the baby in right lateral position a left posterolateral thoracotomy is done through Ihe fourth intercostal space. Lung is retracted anteriorly and mediastind pleura is incised over the aorta and coarctation upto the exit point of the subclavian artery. It is also incised for several centimeters on the dcscendiilg thoracic aorta. Multiple stay sutures are taken after raising mediastinal pleural flaps anteriorly and posteriorly.Dissection is done around subclavian artery, distal arch, coarctation and descending aorta. Ligamenturn arteriosus or ductus when present is dissected and ligated or sutured and divided. Clamp is applied on the proximal aorta including subclavian artery. Distally the clamp is applied on the descending tl~oracic aorta well below the coarcted segment. Intercostal vessels are ligated and divided if they are in the narrow part of post coarct segment. If they need not be sacrificed they are looped for haemostasis. The istl~inus and nairowed portions and coarctation segments are resected. End to end anastomosis is done with 6-0 or 7-0 absorbable sutures. Some surgeons prefer continuous sutures for posterior anastomotic line and interrupted
 |
| Coarctation of aartn-resection and end-to-end anestomosis |
Subclavian Flap Aortoplasty
Jiitial steps are same as for resection and end-to-end anastomosis. After exposina -the entire length of intra thoracic segment of left subclavian artery, it is ligated just proximal to the point of exit from the chest. A clamp is applied on the aortic arch proximal to left subclavian artery. Another clamp is applied on the descending aorta distal to the narrow segment of the descending aorta. Intercostal vessels that need not be divided are looped for temporary control. The transected subclavian artery is incised vertically. Same incision is continued across the coarcted segment on to the descending aorta well below the narrow segment. The intimal shelf of coarctation is excised. The subclavian flap is turned down and anastornosed starting at the apex of the incision on the descending aorta with double armed 6-0 absorbable sutures. Same suture is continued upwards posteriorly and then anteriorly. Distal clamp is removed first and then proxitnal clamp.
Jiitial steps are same as for resection and end-to-end anastomosis. After exposina -the entire length of intra thoracic segment of left subclavian artery, it is ligated just proximal to the point of exit from the chest. A clamp is applied on the aortic arch proximal to left subclavian artery. Another clamp is applied on the descending aorta distal to the narrow segment of the descending aorta. Intercostal vessels that need not be divided are looped for temporary control. The transected subclavian artery is incised vertically. Same incision is continued across the coarcted segment on to the descending aorta well below the narrow segment. The intimal shelf of coarctation is excised. The subclavian flap is turned down and anastornosed starting at the apex of the incision on the descending aorta with double armed 6-0 absorbable sutures. Same suture is continued upwards posteriorly and then anteriorly. Distal clamp is removed first and then proxitnal clamp.
 |
| Subclavian flap aortoplasty |
Results
Early hospital cieath in isolated coarctation is around 2 to 10 per cent. In many reports, mortality for older babies approaches 0. When there is arch hypoplsia and an arch plasty is to be done mortality goes up to 5 per cent. The long-tcrm survival is good. If patients are operated in the older age group, persistent or rupture and recurrent hypertension is more common. Intra cranial ane~~rysln dissection or aorta are the other conlplications reported.
Early hospital cieath in isolated coarctation is around 2 to 10 per cent. In many reports, mortality for older babies approaches 0. When there is arch hypoplsia and an arch plasty is to be done mortality goes up to 5 per cent. The long-tcrm survival is good. If patients are operated in the older age group, persistent or rupture and recurrent hypertension is more common. Intra cranial ane~~rysln dissection or aorta are the other conlplications reported.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.