What is Resection and Primary End to End Anastomosis ?

For neonates and infants the best operation is resection of coarctation and primary end-to-end anastomosis. With the baby in right lateral position a left posterolateral thoracotomy is done through The fourth intercostal space. Lung is retracted anteriorly and mediastinal pleura is incised over the aorta and coarctation upto the exit point of the subclavian artery. It is also incised for several centimetres on the descending thoracic aorta. Multiple stay sutures are taken after raising mediastinal pleural flaps anteriorly and posteriorly.

Dissection is done around subclavian artery, distal arch, coarctation and descending aorta. Ligamenturn arteriosus or ductus when present is dissected and ligated or sutured and divided. Clamp is applied on the proximal aorta including subclavian artery. Distally the clamp is applied on the descending thoracic aorta well below the coarcted segment. Intercostal vessels are ligated and divided if they are in the narrow part of post coarct segment. If they need not be sacrificed they are looped for haemostasis. The isthmus and narrowed portions and coarctation segments are respected. End to end anastomosis is done with 6-0 or 7-0 absorbable sutures. Some surgeons prefer continuous sutures for posterior anastomotic line and interrupted sutures for anterior layer.

Figure: Coarctation of aorta-resection and end-to-end anestomosis

When coarctation extends to the distal arch and when the arch is hypoplastic, arch reconstruction is done by applying clamp between innominate artery and left carotid artery. After resection the descending aorta is mobilized and anastornosed to the under aspect of arch,
The same operation can be done for children. However dissection has to be more careful as the intercostal vessels are thinned out and at times aneurysmal. Anaesthetist uses controlled hypotension at the time of dissection. Mobilisation is more difficult and if there is long segment coarctation interposition Dacron grafting may have to be done.