COARCTATION - DO WE NEED TO RESECT DUCTAL TISSUE

A review of the literature as well as a retrospective review of 100 neonates undergoing operation for coarctation at Children's Hospital in Boston between 1972 and 1984 has not established clear superiority for either resection and end-to-end anastomosis or subclavian flap aortoplasty with respect to risk of recurrent coarctation. However, there is histological evidence that the juxtaductal coarctation shelf is composed of smooth muscle of ductal origin, which subsequently fibroses. This abnormal tissue may be at risk for late aneurysm development, particularly if balloon dilation angioplasty is required. The fact that this abnormal tissue is not removed by the subclavian flap procedure is one of the inherent disadvantages of that procedure. Other disadvantages include the need to sacrifice the left subclavian artery and the fact that, unlike resection and end-to-end anastomosis, the subclavian flap procedure does not lend itself to augmentation of the hypoplastic distal aortic arch. Furthermore, occasionally a secondary coarctation membrane is present within the distal aortic arch, and though it is readily detected during the resection procedure, it can be missed with the subclavian flap procedure. Based on these considerations rather than on a demonstrated superiority of either procedure, my colleagues and I currently prefer resection and end-to-end anastomosis over subclavian flap aortoplasty.