Brief Communication

Ascending Aortic Slide for InterruptedAortic Arch Repair

Miguel Urencio, MD1, Ali Dodge-Khatami, MD, PhD2,Chris E. Greenleaf, MD1, Giorgio Aru, MD1, and Jorge D. Salazar, MD2

AbstractFor repair of interrupted aortic arch, unfavorable anatomy challenges a tension-free anastomosis. We describe a useful alternativesurgical technique used in five neonates/infants, involving splitting the ascending aorta from the sinotubular junction to the archorigin, leftward and posterior ‘‘sliding’’ of the flap with anastomosis to the distal arch creating a native tissue bridge, andreconstruction with a patch. With wide interruption gaps between proximal and distal aortic portions, the ascending aortic slide isa safe and reproducible technique, providing a tension-free native tissue bridge with potential for growth, and a scaffold for patchaugmentation in biventricular hearts, or for Norwood stage I in univentricular palliation.

Keywordsinterrupted aortic arch, aortic arch, CHD (congenital heart disease)

Submitted February 02, 2016; Accepted May 14, 2016.

Background

Surgical repair is the definite treatment for interrupted aortic

arch (IAA). Standard techniques include direct aorta-to-aorta

anastomosis, requiring extensive mobilization of the descend-

ing aorta to reach the ascending aorta. The use of an anterior

patch at the anastomosis to augment the aortic arch serves to

reduce anastomotic tension and may reduce the incidence of

restenosis1 and tracheobronchial compression. When residual

or recurrent aortic arch obstruction occurs,2 angioplasty or reo-

peration may be required if angioplasty is unsuccessful.3

In difficult situations, when the gap between the proximal

and the distal portions of the arch is too far apart and a direct

native tissue anastomosis is not deemed possible, the use of an

interposition graft to restore continuity between the ascending

and the descending aorta may be necessary. The major draw-

back is the inability of the graft to grow with the patient, uni-

versally requiring a reoperation.3 Left bronchial compression is

also not a uncommon and troublesome complication seen after

direct anastomosis or prosthetic graft interposition.4

Native tissue-to-tissue reconstruction is always preferred

when possible to preserve the potential for growth of the repair.

Using a technique where the ascending and descending aortic

segments are incised longitudinally and anastomosed in a side-

to-side fashion, Jacobs et al incorporated the aortic branches in

the anastomosis with good results.5 The subclavian rotational

flap is another alternative, where an end-to-end anastomosis

between the subclavian artery and ascending or descending

aorta (Blalock-Park procedure) is performed. Although this

option uses autologous tissue, it has the great disadvantage of

sacrificing a major artery to the upper extremity.6

Dr William I. Norwood long ago proposed repairing IAA

using entirely autologous tissue to constitute the greater curve

of the reconstructed arch, together with a vascular homograft

patch to augment the lesser curve. During the first case

described in the present series, one of our coauthors who had

seen Dr Norwood perform arch repair decades ago suggested it

as an alternative. We have selectively needed the technique in

five neonates/infants with IAA and a wide interaortic interrup-

tion gap (Figure 1), suggest calling it an ascending aortic slide,

and review our initial experience.

Materials and Methods

This is an observational and retrospective study. After approval

by the institutional review board, we reviewed the Pediatric and

Congenital Heart Surgery database and reviewed patients who

1 Division of Cardiothoracic Surgery, University of Mississippi Medical Center,

Jackson, MS, USA2 Children’s Heart Center, University of Mississippi Medical Center, Jackson,

MS, USA

Corresponding Author:

Ali Dodge-Khatami, Children’s Heart Center, University of Mississippi Medical

Center, 2500 North State Street, Room S345, Jackson, MS 39216, USA.

Email: adodgekhatami@umc.edu

World Journal for Pediatric andCongenital Heart Surgery2016, Vol. 7(5) 645-648ª The Author(s) 2016Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/2150135116655124pch.sagepub.com

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underwent IAA with the ascending aorta slide technique from

April 2010 to September 2015.

The medical records of each patient were reviewed for

demographic data, diagnosis, pediatric intensive care unit

stay, hospital stay, cardiopulmonary bypass time, antegrade

cerebral perfusion (ACP) time, early and late complications,

echocardiographic and cardiac catheterization assessments,

recurrent or residual aortic stenosis, and the need of reinter-

vention or reoperation. Follow-up data were obtained from

the last clinic visit.

Surgical Technique

Through standard median sternotomy, either the distal ascend-

ing aorta just proximal to the innominate artery takeoff or a side

graft to the innominate artery is cannulated for proximal arter-

ial inflow, together with a Y-connector with ductal cannulation

for lower body perfusion, according to surgeon preference.

Standard bicaval cannula is performed, the head vessels pre-

pared for ACP, and bilateral cerebral and somatic near-infrared

spectroscopy monitoring used. At moderate hypothermia

(25�C-26�C), the aorta is cross clamped, cardioplegia given,

antegrade cerebral perfusion commenced with flows of 50 to

60 ml/kg/min, the ductus ligated and transected, and all ductal

tissue excised. The pulmonary artery bifurcation at the site of

ductal transection is closed. The medial ascending aorta is split

into half longitudinally from the sinotubular junction up to the

arch origin (Figure 1). The resultant flap of ascending aorta is

rotated leftward and posteriorly toward the distal aortic portion

and used as a posterior bridge of native tissue to connect the

proximal and distal parts of the interruption, thereby becoming

a neotransverse arch. Depending on the angle or rotation of the

proximal flap to its distal aortic attachment, slight kinking may

be apparent on the external appearance of this greater curvature

reconstruction (Figure 2). However, after a patch is used to

augment and reconstruct the lesser curvature of the aortic arch,

it more than makes up for the acute angle (Figure 2 insert). In

univentricular palliation, after performing a Damus-Kaye-

Stansel anastomosis, this scaffold with the ascending aortic

slide flap is used as part of the Norwood stage I operation.

Results

During the study period, eight patients underwent IAA repair,

five of whom selectively underwent this technique as a better

alternative to other standard approaches (3 males and 2

females). The average age at repair was 26.4 days (range:

7-81 days), and the average weight was 3.07 kg (range:

2.9-3.3 kg). Two (40%) were IAA type B, two (40%) were

IAA type C, and one (20%) was type A. Two patients (40%)

had an aberrant right subclavian artery which was left intact for

the repair. The sizes of the ascending aorta as measured by

preoperative transthoracic echocardiography were 3.8 to

9 mm (mean: 5.6 mm). One patient underwent hybrid palliation

due to sepsis, thrombocytopenia, and pulmonary overcircula-

tion with a ductal stent placed at 22 days followed by bilateral

pulmonary artery banding at 30 days and subsequent IAA

repair at 2.7 months. For the anterior patch of the repair, we

used homograft in three patients and photofixed xenopericar-

dium in two patients.

There was no perioperative mortality. In-hospital, 30-day post-

operative complications included one patient requiring

Figure 1. Insert showing an unfavorable wide gap between proximal and distal portions of the interrupted aorta and proposed incision lines.The ascending aorta is split in half from the sinotubular junction to the arch origin. The patent ductus arteriosus (PDA) has been ligated and allPDA tissue excised.

646 World Journal for Pediatric and Congenital Heart Surgery 7(5)

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extracorporeal membrane oxygenation on the day after surgery

due to hemodynamic instability secondary to refractory junctional

ectopic tachycardia. After 24 hours of support, he was success-

fully decannulated. One patient developed subarachnoid hemor-

rhage on postoperative day 16 secondary to a ruptured left middle

cerebral artery aneurysm requiring surgical clipping on postopera-

tive day 17; the child is asymptomatic today. Two patients had

recurrent laryngeal nerve injury causing left vocal cord paresis

diagnosed by direct laryngoscopy, one of them temporary.

The mean follow-up time was 20 months (range: 2.1-49

months). One patient had balloon angioplasty of the aortic

isthmus due to mild hypoplasia seen on the pre-Glenn cathe-

terization four months after IAA repair. One patient with type

C interruption, subaortic stenosis, and an aberrant right subcla-

vian artery had surgical reintervention due to sub- and supra-

valvar aortic stenosis requiring redo subaortic surgical

myectomy and ascending aortic patch augmentation four

months after IAA repair. Two patients underwent single-

ventricle palliation strategy. Both had successful Glenn opera-

tions and one of them eventually a Fontan completion. One late

death was recorded in the second patient awaiting Fontan com-

pletion, 2 years and 3 months after IAA repair, being 1.9 years

after Glenn palliation, secondary to influenza A infection.

Conclusion

The ascending aortic ‘‘slide’’ is a safe, effective, and reprodu-

cible technique for IAA repair, in difficult anatomic conditions

where more conventional techniques are judged suboptimal or

will not allow for a tension-free repair. It has the advantage of

using a native tissue-to-tissue anastomosis with the potential to

grow as well as providing a good posterior scaffold to facilitate

anterior patch reconstruction. This can be used for biventricular

hearts or as part of the Norwood stage I for univentricular

palliation. It is not technically more demanding, nor does it

increase antegrade cerebral perfusion, cross clamp or bypass

times, does not require sacrificing any major vessels, and does

not tether or compress the airway. Small ascending aortas may

be a contraindication or limiting factor to the ‘‘slide’’ opera-

tion; however, no cutoff value can be suggested from our lim-

ited experience. We have used the technique in neonates with

ascending aortas as small as 3.8 mm, although we recognize

that splitting an already small ascending aorta, especially in the

setting of a type C interruption and/or an aberrant right sub-

clavian artery, may lead to future supravalvar aortic stenosis.

Longer follow-up will be needed to confirm the initial satisfac-

tory results in what is proposed as a useful alternative technique

in selected cases. Limitations of the study include the retro-

spective nature of analysis, the small number of patients, and

lack of comparison to more standard techniques for the repair

of IAA in an already rare diagnosis.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

Figure 2. The flap has been rotated leftward and posteriorly toward the descending aorta and used as a posterior bridge of native tissue formingthe neo-greater curvature. The completed lesser curvature arch reconstruction with a patch is in the insert.

Urencio et al 647

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