Type A Interrupted Aortic Arch Repair and Pulmonary Artery Banding Through a Left Posterolateral Thoracotomy

This video illustrates the case of a 10-day-old female neonate (2.8 kg) with antenatal diagnosis of Type A interrupted aortic arch (IAA). Preoperative echocardiography showed Type A interrupted aortic arch, large perimembranous and mid-muscular ventricular septal defects (VSDs), large constricting patent ductus arterios (PDA) continuing as the descending aorta, and good biventricular function.

Operative Steps

Through a left posterolateral thoracotomy, the lung was retracted anteriorly, and the descending thoracic aorta, aortic arch, and PDA were carefully dissected. The PDA was ligated and divided, and all ductal tissue was completely excised. The descending aorta was transected distal to the ductus. After clamping (proximal clamp distal to the innominate artery, distal clamp beyond the second intercostal artery), the proximal arch was opened, and an end-to-end anastomosis was performed with the descending aorta. The pericardium was then opened anterior to the phrenic and vagus nerves to expose the main pulmonary artery (PA). PA banding was performed below the origin of the right pulmonary artery using polytetrafluoroethylene (PTFE) material, allowing precise adjustment of band tightness.

There are several key learnings demonstrated by this surgery. Complete excision of ductal tissue is essential to prevent restenosis. Ensuring proximal clamp placement preserves flow to the innominate artery. Distal clamp placement beyond the second intercostal artery provides adequate operative space. Adequate dissection and mobilization of the descending aorta and first two intercostal arteries are critical for tension-free anastomosis. In neonates, the descending aorta can usually be mobilized up to 1 cm. And positioning the PA band below the origin of the right pulmonary artery is necessary to avoid branch distortion.

Outcome

Postoperative echocardiography showed laminar flow through the reconstructed arch and a PA band gradient of 40 mmHg. The postoperative course was uncomplicated. The patient was extubated on postoperative day one and discharged home in stable condition on postoperative day six.

This technique offers an effective alternative to conventional bypass repair and can reduce or avoid the inflammatory response from cardiopulmonary bypass, especially in neonates and low birth weight babies. This technique is suitable for selected neonates with Type A IAA and favorable arch anatomy, particularly when associated intracardiac lesions such as VSDs can be managed in a staged fashion.

References

1. Wu SJ, Fan YF, Tan YH, et al. Staged surgical repair for infants with interrupted aortic arch. Asian J Surg. 2020;43(11):1074-1077. doi:10.1016/j.asjsur.2020.02.013
2. Di Pasquale L, Dranseika V, Erdil T, Prêtre R, Dave H. Two-stage repair of interrupted aortic arch type A: Arch reconstruction and pulmonary artery banding without CPB through a left thoracotomy. Multimed Man Cardiothorac Surg. 2020;2020:mmcts.2020.035. doi:10.1510/mmcts.2020.035
3. Kouchoukos NT, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/Barratt-Boyes Cardiac Surgery. 4th ed. Elsevier; 2013.

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