Jorge L. Pinzon, MD #{149} Patricia E. Burrows, MD, FRCPC #{149} Lee N. Benson, MD, FACC, FRCPC C. A. Frederic Mo#{235}s,MD #{149} Nancy E. Lightfoot, PhD #{149} William G. Williams, MD, FRCSC Robert M. Freedom, MD, FACC, FRCPC
Repair ofCoarctation in Children: Postoperative To determine the morphologic sequelae after surgical repair of coarctation of the aorta, the authors retrospectively reviewed angiograms and hemodynamic and clinical data on 215 patients who underwent cardiac catheterization after surgical repair of coarctation of the aorta during a 13year period. Ninety-seven patients (45%) underwent coarctation reseclion with end-to-end anastomosis; 92
ofthe
Aorta Morphology’
variety of surgical repairs of coarctation of the aorta are in current use (1-3). Coarctation resection with end-to-end anastomosis, in spite of recent improvements in technique, is associated
with
a significant
mci-
of repair site to diaphragmatic aorta greater than 1.5. Transverse-arch or isthmic hypoplasia or recoarctation was detected in 86 patients (40%) and was most commonly
(4-6). The suba popular has not (7-10), and aneurysms at the repair site after this procedure have recently been reported (11). Technical modifications have been introduced to avoid redoarctation (12), preserve the arterial blood flow to the left arm (13,14), and increase the diameter of a hypoplastic transverse arch (14-17). Synthetic patch aortoplasty carries the added risks of thrombosis and infection and
associated
may
(43%),
subclavian-flap
angioplasties;
and 26 (12%), synthetic-patch Sixty-four patients (30%) had “aneurysm,”
ment
defined
repairs. an
as a measure-
ratio
with
septal
defects
or ob-
dence of recoarctation clavian-flap arterioplasty, approach in newborns, avoided recoarctation
be associated
with
late
aneurysm
struction of the left ventricular outflow tract. Pullback systolic pressure gradients at catheterization were significantly higher (P .0001) in the
formation (18,19). Recent reports have also described a significant incidence of aneurysms after balloon dilation angioplasty of native coarctation
patients
with
transverse-arch
(20-23).
poplasia
and
recoarctation
=
those
with
diaphragmatic Significant structions
surement diameter
ratios
hy-
than
of transverse
aorta
greater
postoperative
in arch
than arch
to
0.9.
ob-
can be predicted with mearatios on the basis of the of the abdominal aorta.
Index
terms: Aneurysm, aortic, 562.73 #{149} Aorta, stenosis or obstruction, 562.1511 #{149} Aorta, surgery, 562.4545 #{149}Aorta, transluminal angioplasty, 942.454 #{149} Children, cardiovascular system
Radiology
1991; 180:199-203
This study was undertaken to determine the relative incidence of aneurysm formation as well as residual obstruction following three surgical repairs and whether a relationship exists between the development of so-called “aneurysms” and the type of or time since repair. At the same time, this study was to test the usefulness of measurement ratios in predicting postoperative residual arch obstructions. MATERIALS
AND
The records of patients angiography after repair the aorta December
duningJanuany 1988 were
METHODS who underwent of coarctation of
1976 obtained
through from the
From the Department of Diagnostic Imaging (P.E.B., C.A.F.M.), Divisions of Cardiology (J.L.P., L.N.B., N.E.L., R.M.F.) and Cardiovascular Surgery (W.G.W.), and Variety Club Cardiac Cathetenization Laboratories, The Hospital for Sick Children and the University of Toronto, Toronto. From the 1989 RSNA scientific assembly. Received February 9, 1990; revision requested March 27; revision received January 7, 1991; accepted March 21. Address reprint requests to P.E.B., Department of Radiology, The Hospital for Sick Children, 555 University Aye, Toronto, Ont, Canada M5G 1X8. ( RSNA, 1991
computerized
the
angiographic
Hospital
Cardiac
for Sick
data
Children,
catheterization
grams
of 231
cations for phy included lesions sessment
data
patients
recurrent
angio-
reviewed.
mdi-
required further signs of residual
obstruction.
Enlarging
eurysms were diac catheterization
not
before of these
tients.
Sixteen
patients
from
the series
diagnosed in any were
owing
tion 215
of the aortic arch remaining children
the
total
population
coarctation
repair
the
period
13-year The
215
125)
=
were
the the ing
outlines nearest aortograms
made
aortic
mon
with
=
if the aortic arch Measurements
electronic
arch
carotid
systolic (Fig
just
artery;
that portion subclavian
90) or lateral reviewed, and
(ti
were
used only visualized.
toyo, Japan) from following locations
verse
calipers
gin of the ductus aorta at the level the narrowest aorta and their
distal (b) the
to the left cornaortic
errors
arteriosus; of the diaphragm.
caused
ratios
used for the aorta relatively
statistical analysis. at the level of the constant in relation
size
is unaffected
by
diovascular anomalies normalize the following (a) the transverse aortic
the
data
From was
(fewer
of the
aorta,
of Clarkson
data,
determined
than
for were
As the size diaphragm to patient
associated
and from were
and
a ratio to be
two
of the were
of is
car-
(24), it was used to measurements: arch, (b) the wid-
measurements projections
these
Also,
by correction
measurement
est segment isthmus. Normal giographic
isthmus,
to the left to the onand (c) the
and widest segments location and position
magnification,
and
(Mitu-
frames in the 1): (a) the trans-
of the aorta distal artery and proximal
determined. To avoid
accord-
repair. Cineangreat vessels in
of the aortas were traced to 0.5 mm. In most cases, ascendwere used, while ventnicu-
lograms were was adequately
were
over
grouped
oblique
projections
undergoing
review.
ing to mode of coarctation giograms of the aorta and (ii
The of
27%
institution
of this
patients
visualiza-
796)
=
ancarpa-
at angiography. represent (ii
asor
excluded
to poor
at this
the left anterior
at
and angiogracardiovascular
1) that clinical
arch
and
were
catheterization associated
(Table and
base
Toronto.
standard
(c) the
aortic
similar obtained
Brandt
of less
anfrom
(24).
than
pathologically
deviations
0.9 small
from 199
IA
Table
1
Associated
Cardiac
Lesions
TAA
No. of Patients Type Ventricular
Bicuspid
of Lesion
(n
septal defect aortic valve without
Left ventricular outflow Atrial septal defect Aortic stenosis Mitralstenosis Dextrocardia
aortic stenosis obstruction
tract
Other
Table Figure
1.
Schematic representation aorta. AA = ascending aorta, DA ing aorta, TAA = transverse aortic isthmus, IA = innominate artery,
common tery, C
carotid,
LSA
a = transverse diaphragmatic
=
=
LCC left subclavian
=
arch, aorta.
b
aortic
=
of Aortic
Dilatation
in Three
Type
of Repair
isthmus,
isthmal
hypoplasia
or
aorta
greater
Measurements
from
recordings
were
second
catheterization
the
were
earlier
Type
± 30
those
the
aortic
compared dent
arch
by means
unpaired
5%
level
was
test
was
used
proportions; significant.
t test. considered 5%
for
each
±
mean
2.6 (range,
age
were
level
Stuat the The
differences was
x2
in
29(13) 9(4)
were was
0.002-14.8
5.6 years ± 5.5 (range, 0.02-19.7 years). The elapsed time between
#{149} Radiology
in parentheses
64(30)
are percentages.
between
Type
of Repair
and
of the Aorta at Repair
Morphology with Focal
Site
Bulge
Diffuse (n = 20)
of Repair
Posterior (n = 20)
Anterior (n = 24)
Total (n
Group
215)
=
12
11
3
97
Subclavian-fiap
7
7
15
92
Synthetic-patch
1
2
6
26
Of the 215 patients, 97 (45%) underwent coarctation resection with an end-to-end anastomosis, 92 (43%) underwent
as a first
1.3
years),
was ne-
pair and study averaged 4.2 years ± 4.1 (range, 0.002-15.6 years). Isolated coarctation of the aorta was observed in 43 patients (20%). Associated cardiac lesions were observed in most of the patients (n 172) and are listed in order of frequency (Table 1).
200
215(100)
subclavian-flap
angioplasty,
and 26 (12%) underwent syntheticpatch repair. In 24 patients, syntheticpatch repair was performed to correct recoarctation; in two, it was used to enlarge a hypoplastic transverse arch
considered
at catheterization
=
Site:
± 1
group
A cutoff value significant.
Two-thirds of the patients male. The mean age at repair and
Repair
Diaphragmatic Aorta Ratio > 1.5
26 (12)
End-to-end
RESULTS
years
with
No. of Patients
of
of the two-tailed
to determine the
of Repair
catheterization.
All values are expressed as mean standard deviation. Systolic gradients across
62
patient,
40 months
postoperative
Types
No. of Patients Dilated-Aortic-Segment
were calculated. underwent a
with
1
153
Synthetic-patch
pressure
for each
compared
7
5
26(13)
Table 3 Relationship
after the initial study; the angiographic measurement ratios and systolic catheter gradients
10
17
97 (45)
1.5 (11,19).
pullback
and the systolic gradients A subgroup of 33 patients
27
86)
=
recoarcta-
than
obtained
39 12 24 18
92 (43)
Note-Values
tion in our population. Aneurysmal dilatation was defined as in the literature: a ratio of the dilated aortic segment to diaphragmatic
100 51 40 39
End-to-end Subclavian-flap
Total
and
(n
ar-
the mean) for both transverse arch:diaphragmatic aorta and isthmus:diaphragmatic aorta ratios and was used to define the presence of transverse-arch hypoplasia
Transverse.Arch
Hypoplasia
Patients
left
=
215)
2
Prevalence
of the descendarch, I =
=
No. of Patients with
procedure.
The
mean
ratio
ences in the percentage of patients with an aneurysm after the three types of repair (P = .659). However, the morphology of the aorta at the repair site appeared to be related to the type of repair. Most aneurysms in patients with subclavian-flap angioplasties
and
synthetic-patch
repairs
were
of
repair site to diaphragmatic aorta measurement for the group of 215 patients was 1.45 ± 0.3. Sixty-four patients (30%) had an aneurysm (ratio > 1.5 at the repair site) (Table 2). The morphology of the aorta at the repair site consisted of diffuse enlargement without focal bulging of the wall in 20 patients, a focal posterior bulge in 20, and an anterior focal bulge in 24. There were no significant differ-
directed anteriorly (Fig 2), while 88% of the patients with an aneurysm after coarctation resection with endto-end anastomosis showed a predominance of posterior bulges or diffuse enlargement (Figs 3, 4); anterior bulges developed in just three patients (Table 3). There was no relationship between the presence of an aneurysm and time elapsed after repair, repair type, or age at the time of repair. Thirty-three patients in this series underwent a second postoperative
July 1991
Table 4 Measurement
Ratios Ratios Ratios and Ranges for Total Group (n = 215)
Ratios Transverse aortic arch to diaphragmatic aorta Repair site to diaphragmatic Isthmus
0.96
0.23
aorta
± 0.25 (0.45-1.78) 1.44 ± 0.27 (0.80-2.44)
Note-Ratios
are presented
as means
1 standard
±
deviation.
Values in parentheses
of Repair
Synthetic-Patch (n
0.90 ± 0.18 (0.53-1.40) 1.44 ± 0.30 (0.73 ± 2.52) 1.23 ± 0.28
1.18 ± 0.26 (0.51-1.91)
(0.48-1.95)
and Ranges by Type Subclavian-Flap (n = 92)
0.99
(0.45-1.96) 1.46 ± 0.29 (0.74-2.52) 1.20 ± 028
aorta
to diaphragmatic
±
End-to-End (n = 97)
26)
=
1.08 ± 0.26 (0.67-1%) 1.57 ± 0.34 (1.05-2.28)
1.25
(0.48-1.90)
0.35
±
(0.53-1.95)
are ranges.
Figure 4. Aortogram obtained in axial left anterior oblique projection shows focal
Figure
2. Aortogram shows anterior 3.6 years after
jection patient plasty.
obtained in lateral probulge in a 3.7-year-old subclavian-flap arterio-
bulge, predominantly synthetic-patch-repair year-old patient Figure 3. Aortogram obtained in left antenor oblique projection shows transverse-arch hypoplasia plus postcoarctotomy posterior bulge with end-to-end anastomosis in a 7.7year-old patient 7.6 years after repair.
struction;
catheter study the initial one.
40 months The mean
operative
site:diaphragmatic 0.25 at the first
ratios study and
were 1.45 1.4 ± 0.26
the
second
surement
ratio
The
increased
±
at
mea-
significantly
in only one child, from 1.34 to 1.51, oven 21 months. The configuration of the aneurysm did not change. Measurement ratios for each repair are
in Table
poplasia
4. Transverse-arch
was
present
hy-
in 86 (40%)
of
and four (2%), a synrepair. There was no rela-
tionship
and (P
had sia;
between
patient .129).
=
age One
recoarctation 101
Volume
of these
180
arch
at the
hypoplasia
time
hundred
of repair fifty
or isthmic also
had
#{149} Number
1
patients
hypopla-
a hypoplas-
tic transverse
arch.
These
was
used
to
obstruction.
DISCUSSION
outcomes
were not related to type of surgical repair. The hemodynamic impact of the angiographic observations was assessed
with
systolic
gradients
time of catheterization mean systolic arch similar
215 patients: 36 (17%) had undergone coarctotomy with end-to-end anastomosis; 46 (21%), a subclavian-flap
angioplasty; thetic-patch
of 0.9
residual
at the site of in a 10.2repair.
30 after
±
catheterization.
10.1
a ratio
define
posterior, angioplasty years after
at the
among the three (P = .5362) (Fig 5).
types
of re-
ratio
(arch
or isth-
mus:diaphragmatic
aorta)
to 0.9 correlated
less
with
than
a clini-
observed in patients with recoarctation, transverse-arch
hypoplasia, (P = .0001)
and
than
recoarctation
in those
without
ob-
of co-
are influenced
of the lesions,
aortic arch, and mode
of repair attempted
(11,18,19,25,26). Our to define whether
study there
was
relationship
repair
any
late
aneurysm
of coanctation
iso-
correction
aorta
among
type, aneurysm formation time elapsed after repair. Previous studies have on
cally significant obstruction measured by means of catheter gradient. Significantly higher gradients (P = .0002)
were lated
of surgical
of the
by the morphology associated cardiac
(Table 5). The gradients were
pair A measurement equal
Results
arctation
thetic
materials
(1), and identified
formation
of the
after
aorta
(18,19,25,27)
repair
with and
synafter
subclavian-flap arterioplasty (11), defining the presence of an aneurysm with a measurement ratio greater than 1.5 for the repair site:diaphragmatic aorta (11,19). Many of these aneurysms
are
detected
as enlarging
Radiology
#{149} 201
masses
on
routine
chest
radiographs,
but some have ruptured, with fatal outcome. A true aneurysm is one in which the wall is formed by the stretched tissue of the artery itself, whereas a false aneurysm develops when blood leaks out of the artery
and
excavates
rounding
Our in
a cavity
tissues
review 30%
of
all
trihution
or
in the
identified
true
aneurysms
patients,
with
equal
to repair
type,
suhclavian-flap
66%
with
of synthetic-patch
70
60
50%
an
a few
repairs
were
present
weeks
after
aneurysms
probably
liberate achieve as
attempt as large
possible
end-to
at
angiogra-
surgery.
These
represent
or a combination
of preex-
dilatation
by Olsson et al (27). These implicated the effect of dif-
tensile
strengths
a noncompliant Other studies, have suggested lack
the
with
the
lamina
the
patch
of a collagen
scar
may
factors (29). More has been expressed intimal
in the and
the
aortic
resection
carried
to resect Infection
have other
also been considered among possible stimuli of aneurysm (18). early
after
The
the and
presence
surgery,
relationship with time after and the lack of significant serial examinations of some children indicate that most aneurysms do not progress during childhood, but grow child. The factors that cause
202
#{149} Radiology
wall
exout
posterior thrombosis
of aneulack of repair, change at of these of these or regress with the some of
the
have In 40% and
Pullback
flap
synthetic
patch
systolic
aneurysms
gradients
to grow
later
by type
OF
REPAIR
of repair.
in life
not been revealed by this study. our study group of 215 patients, had transverse-arch hypoplasia 29% had recoarctation. The study was biased as residual
toward obstruction
interpreting
other
aminations,
such
these
diagwas one
raphy
and
aortic-imaging as computed
magnetic
extomog-
resonance
imag-
ing. rate
and
residual
after
three
Last,
this
report
of so-called
outlines
a
aneurysms
aortic-anch different
obstructions types
measurement
the diameter
concern the
repair (25,26).
rysms
subclavian
of repair.
The presence of a focal enlargement of the aorta at the repair site appears to be a common angiographic finding.
presence
during shelf
formation
of
be contributing
recently, regarding
these
5.
In summary,
aor-
use
Figure
similar
foreign material. based on histology, that the additional
of elastic
opposite
tensive
across
in conjunction
a
obstruction and an angiographic ratio of 0.9 or less for the transverse arch on isthmus. These data may be useful in
after synthetic patch repair is compliance mismatch, or maldistribution of mechanical forces in the aortic wall,
tic wall
S
of the indications for cardiac catheterization. No relationship was observed among arch hypoplasia, type of repair, aneurysm formation, or age. Our data have shown a good correlation between significant hemodynamic
type of repair raises questions concerning etiology. A widely accepted theory about aneurysm formation
ferent
end
TYPE
group noses,
a de-
by the surgeon to a diameter of repair
poststenotic
postulated authors
!---
8
show-
and redundant patch. The lack of relationship between the presence of an aneurysm and the isting
-
bulge
anterior
aneurysms
phy
-
of
0
and
at the repair site in the left anterior oblique or lateral projection at angiography. The antenor bulge may be due to a combination of the ductal ampulla and the oblique aortoplasty suture line. There was no clear relationship between the presence of an aneurysm and time elapsed after repair. In some patients, ing
I
dissurgical of the to be
arterioplasties
0
U
(28).
of the three repair groups. The morphology aneurysm, however, appeared
0
80
sur-
adventitia
in each
related
90
of the
ratios
involving
aorta
at the
level
of the diaphragm as the normalizing factor are useful in predicting hemodynamically significant arch obstructions. U Acknowledgments: sistance Scorizzi
We acknowledge
of Cameron Finlay, in the preparation
3.
4.
5.
the as-
BSc, and Susan of this manuscript.
6.
References 1.
2.
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#{149} 203