One year old asymptomatic girl. Clinical and echocardiographic evidence for aortic coarctation. Transfemoral catheterization and aortography confirmed the diagnosis: ascending aortic pressure 130mmHg (peak), descending aortic pressure 80mmHg (peak). The catheter entered the right subclavian artery before passing through the coarctation. The pressure waveform in the right subclavian artery and in the descending aorta were identical.
Early and late phases permit the diagnosis of: aortic coarctation and aberrant right subclavian artery.
Operative management: the chest was entered through the left
fourth intercostal space. After dividing the first intercostal vein, the
pleura was opened over the descending aorta and left subclavian artery.
The ligamentum arteriosum was divided. The coarctation site was identified
by observing the pattern of pulsation in the isthmic region: the coarctation
was located directly proximal to the ligamentum. The poststenotic aorta
was not dilated. The right subclavian artery originated just beyond the
coarcation from the posterior aspect of the aorta. Mobilization of the
descending aorta, subclavian arteries and aortic arch. It was noted that
the intercostals were very small. When clamps were temporarily placed on
the aorta between the left subclavian and the coarc, on the distal aorta,
and on the right subclavian artery, the distal aorta COLLAPSED. I removed
the clamps and after some thought elected to use a shunt from the aortic
arch to the distal descending aorta. I selected one of the shunts we use
for carotid artery surgery and placed it via pursestring sutures at the
aortic arch and the descending thoracic aorta.The distal arch was clamped
between left subclavian and coarctation, the descending aorta beyond the
coarcation, and a bulldog clamp was placed on the aberrant right subclavian
artery. The coarctation segment was resected. The aorta was reanastomsed
with a running 6-0 polydioxanone suture. The child was extubated in the
OR and recovered without complications. Control echocardiography showed
normal flow in the descending aorta.
last update Nov 17, 1999