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Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation
Insights
The Vossschulte isthmoplasty technique for coarctation of the aorta can lead to dangerous postoperative aneurysms. Resection of the posterior fibrous ridge is a key risk factor, necessitating a critical re-evaluation of this surgical approach.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Surgical Pathology
Background:
- The Vossschulte isthmoplasty technique was the primary surgical treatment for coarctation of the aorta at our institution from 1957 to 1984.
- A total of 317 patients underwent this procedure, with 54 being infants under 12 months old.
Purpose of the Study:
- To investigate the cause of a high incidence of postoperative aneurysms following Vossschulte isthmoplasty.
- To evaluate the long-term safety and efficacy of this surgical technique for coarctation of the aorta.
Main Methods:
- Retrospective analysis of 317 patients treated with Vossschulte isthmoplasty for coarctation of the aorta.
- Review of medical records, imaging, and pathological findings in patients who developed postoperative aneurysms.
- Analysis of reoperation data for late aneurysms.
Main Results:
- Hospital mortality was 15% for infants (<1 year) and 3% for older patients.
- Postoperative aneurysms were detected in 18 patients during follow-up.
- Reoperation for late aneurysms was performed in 15 patients.
- Extensive resection of the aortic isthmus fibrous membrane was identified as a predisposing factor.
- Microscopic examination revealed medial degeneration in over half of the aneurysmal walls.
Conclusions:
- Extensive resection of the posterior fibrous ridge during Vossschulte isthmoplasty is a significant risk factor for developing late aortic aneurysms.
- The Vossschulte technique for coarctation of the aorta requires critical re-evaluation due to the high rate of aneurysm formation.
- Surgical modification to avoid excision of the posterior fibrous ridge is recommended.
Abstract:
From 1957 to 1984 direct and indirect isthmoplasty as described by Vossschulte has been the method of choice for surgical therapy of coarctation of the aorta in our hospital. A total of 317 patients have been so treated, 54 of whom were less than 12 months old at operation. The hospital mortality in this group was 15% and the mortality in patients older than 1 year was 3%. The early results were encouraging, but during follow-up an increasing number of postoperative aneurysms have been detected. During reinvestigation an aneurysm was diagnosed in 18 cases. Therefore, we have studied the cause of these aneurysms. To this point reoperation has been performed in 15 patients having late aneurysms. Extensive resection of a fibrous membrane of the aortic isthmus at the first intervention seems to be an essential predisposing factor for development of aneurysms. Microscopic examination of the aneurysmal wall revealed degeneration of the media in more than half of the patients. From our experience we conclude that the posterior fibrous ridge should no longer be excised and the Vossschulte operative technique should be viewed more critically.