Title

Bovine Arch Anatomy Influences Recoarctation Rates in the Era of the Extended End-to-End Anastomos

Authors

Document Type

Poster

Publication Date

11-9-2018

Abstract

Objectives: Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to: 1) assess chart review reliability in bovine arch identification, 2) determine recoarctation risk with a bovine arch, and 3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. Patients and Methods: 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). Echocardiograms from these patients were reviewed for arch anatomy and compared to the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair ≥20 mmHg. For cases with angiographic images, a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. Results: Chart review identified 6.1% of patients with a bovine arch, compared to 28.6% on targeted image review. 28.6% of bovine arch patients had a follow-up gradient ≥20mmHg. Only 5.7% of normal arch branching patients had a follow-up gradient ≥20mmHg. The mean clamping index was significantly diminished in patients with bovine arch anatomy. Conclusions: Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should trigger a profound paradigm shift in preoperative assessment, parental counseling and surgical approach for children with discrete aortic coarctation. Objectives: Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to: 1) assess chart review reliability in bovine arch identification, 2) determine recoarctation risk with a bovine arch, and 3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. Patients and Methods: 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). Echocardiograms from these patients were reviewed for arch anatomy and compared to the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair ≥20 mmHg. For cases with angiographic images, a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. Results: Chart review identified 6.1% of patients with a bovine arch, compared to 28.6% on targeted image review. 28.6% of bovine arch patients had a follow-up gradient ≥20mmHg. Only 5.7% of normal arch branching patients had a follow-up gradient ≥20mmHg. The mean clamping index was significantly diminished in patients with bovine arch anatomy. Conclusions: Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should trigger a profound paradigm shift in preoperative assessment, parental counseling and surgical approach for children with discrete aortic coarctation. Objectives: Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to: 1) assess chart review reliability in bovine arch identification, 2) determine recoarctation risk with a bovine arch, and 3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. Patients and Methods: 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). Echocardiograms from these patients were reviewed for arch anatomy and compared to the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair ≥20 mmHg. For cases with angiographic images, a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. Results: Chart review identified 6.1% of patients with a bovine arch, compared to 28.6% on targeted image review. 28.6% of bovine arch patients had a follow-up gradient ≥20mmHg. Only 5.7% of normal arch branching patients had a follow-up gradient ≥20mmHg. The mean clamping index was significantly diminished in patients with bovine arch anatomy. Conclusions: Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should trigger a profound paradigm shift in preoperative assessment, parental counseling and surgical approach for children with discrete aortic coarctation.

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