Vitullo D A, DeLeon S Y, Graham L C, Eidem B W, Roughneen P T, Javorski J J, Cetta F
Department of Pediatrics, Loyola University Medical Center, Stritch School of Medicine, Maywood, Illinois 60153, USA.
Ann Thorac Surg. 1999 Feb;67(2):528-31. doi: 10.1016/s0003-4975(98)01254-5.
Treatment of hypoplasia of the entire arch in coarctation is a surgical challenge. The current approaches have technical difficulties, high recurrence rates, and increased morbidity and mortality.
Over a 14-month period, a combined extended end-to-end repair with patch enlargement of the concavity of the entire arch was performed in 6 neonates and 1 infant. Through a midsternotomy and using cardiopulmonary bypass and hypothermia, extended end-to-end repair was performed initially leaving the proximal anastomosis open. The enlarging polytetrafluoroethylene patch was then sutured starting at the incised descending aorta distal to the extended end-to-end repair and continued retrogradely through the transverse arch to the ascending aorta proximal to the aortic cannulation site. One neonate had a patent ductus arteriosus and another had ventricular septal defect closure. One neonate had arterial switch and 3 had Norwood-type procedures performed with the enlarging patch extended to the pulmonary artery anastomosis. The remaining infant had arch enlargement performed after an arterial switch procedure and extended end-to-end repair.
All patients did well and showed no residual gradient up to 1 year follow-up. Two patients successfully had bidirectional Glenn shunt at 9 months of age, and one had closure of residual arterial septal defect at 8 months of age.
The combined extended end-to-end repair and arch enlargement procedure should minimize recurrence rates because of a tension-free enlargement of the entire aortic arch and elimination of the coarctation ridge and ductile tissues. Combined with the arterial switch and Norwood-type procedures, the approach results in a large neoaorta.
治疗缩窄时整个主动脉弓发育不全是一项外科挑战。目前的方法存在技术难题、高复发率以及发病率和死亡率增加的问题。
在14个月的时间里，对6例新生儿和1例婴儿实施了联合扩大端端修复术并使用补片扩大整个主动脉弓的凹面。通过正中胸骨切开术并使用体外循环和低温技术，最初进行扩大端端修复，近端吻合口保持开放。然后从扩大端端修复远端的切开降主动脉开始缝合扩大的聚四氟乙烯补片，并逆行穿过横弓至主动脉插管部位近端的升主动脉。1例新生儿有动脉导管未闭，另1例进行了室间隔缺损修补。1例新生儿进行了动脉调转术，3例进行了诺伍德式手术，扩大补片延伸至肺动脉吻合口。其余婴儿在动脉调转术和扩大端端修复术后进行了主动脉弓扩大术。
所有患者情况良好，在长达1年的随访中均未显示残余压差。2例患者在9个月大时成功进行了双向格林分流术，1例在8个月大时闭合了残余动脉导管未闭。
联合扩大端端修复和主动脉弓扩大术应能将复发率降至最低，因为整个主动脉弓实现了无张力扩大，消除了缩窄嵴和易延展组织。结合动脉调转术和诺伍德式手术，该方法可形成一个大的新主动脉。
