Surgical treatment of coarctation in small infants: our experience

We read with great interest the article by Barreiro et al. [1] regarding the current role of subclavian flap aortoplasty (SFA) in the surgical treatment of coarctation in infancy. We are in complete agreement with the authors that the SFA still has a role in isolated isthmic coarctation repair, in infancy as well as in the most difficult subgroups of patients operated in neonatal age. In fact, the technique itself allows excellent aortic continuity with naturally harmonious restoration of the aortic arch—isthmus tract. These goals are not foreseen either with patch aortoplasty or with endto-end (ETE) anastomosis, both of which, respectively, distort and eliminate the stenotic thoracic aorta. If the hypoplasia of the aortic arch is mild-to-nil, the physiological antegrade flow through the arch and the absence of gradient at the end of the procedure will guarantee adequate longterm repair, in most cases. In our institute, 178 patients presenting with neonatal coarctation were operated. In the search for the (perhaps utopic) ideal surgical management, we have changed our surgical strategy over the years in our institute. In the earlyto-mid phase of our activity we proposed a patch aortoplasty for all neonates that has the advantage of always relieving the gradient at the level of the isthmus by means of a technique which is both timeand hemorrhage-controlled. The incidence of aneurysm formation in the long term (2/178 in our experience at a follow-up of 10 years, but frequently reported in the literature [2] to longer follow-up) and the high rate of recoarctation (26%) discouraged us from electively employing the patch. After a period of non-randomized surgical strategy of SFA, extended ETE (EETE) anastomosis and ETE anastomosis technique, in our institute we currently adopt the following strategies: