Coarctation of the Aorta Repair

Coarctation of the aorta is a narrowing of the aorta, most often where the ductus arteriosus joined it, just beyond the left subclavian artery. Ductal tissue that grows into the aortic wall is the usual cause. In a newborn, the ductus may be what keeps blood flowing to the lower body; when it closes, the baby can collapse with shock, low urine output and acidosis and needs medicine (prostaglandin) and stabilization before surgery. An older child may have no symptoms, but has high blood pressure in the arms and weak or absent pulses in the legs, with large collateral vessels growing around the narrowing. Coarctation often comes with other heart defects. Most repairs are done through a left posterolateral thoracotomy without the heart-lung machine. The classic repair cuts out the narrowed piece and sews the ends together. Many surgeons now use an extended end-to-end repair for infants: the join is carried up under the arch to widen a small arch as well. Other methods include the subclavian flap (the left subclavian artery is turned down as a patch), a synthetic patch (now rare because of late aneurysms), and a tube graft for older children and adults. A median sternotomy with bypass is used when the arch is very small or other heart defects are repaired at the same time. Balloon dilation and stents are alternatives in some patients. The most feared complication is paraplegia from poor blood flow to the spinal cord while the aorta is clamped, which is why clamp time is kept short and the pressure above the clamp is kept up. Other risks are bleeding from collateral vessels, injury to the recurrent laryngeal nerve, chyle leak, high blood pressure after surgery, and the narrowing coming back. For the scrub: many ties, a ready ESU, vascular clamps and fine polypropylene.