(Circulation. 1995;92:132-136.)
© 1995 American Heart Association, Inc.
Articles |
Coarctation of the Aorta
Repair With Polytetrafluoroethylene Patch Aortoplasty
From the Divisions of Cardiovascular-Thoracic Surgery (C.L.B., K.P., C.M.) and Cardiology (V.R.Z., T.J.W.), The Children's Memorial Hospital, and the Departments of Surgery and Pediatrics, Northwestern University Medical School, Chicago, Ill.
 |
Abstract |
|---|
 Top Abstract IntroductionMethods Results Discussion References |
|---|
Background The first successful surgical repair of coarctation of the aorta (CoAo) was performed in 1944, but during the years that followed a high incidence of recoarctation was seen, ranging from 20% to 86%. In response to that problem, the patch aortoplasty was introduced in 1957; however, true aneurysms were found in the aortic wall opposite the patch after Dacron patch aortoplasty, particularly when the coarctation ridge was excised. The purpose of our review was to evaluate the results of patch aortoplasty for CoAo using a relatively new material, polytetrafluoroethylene (PTFE), and an operative technique that does not involve resection of the coarctation ridge.
Methods and Results Between 1979 and 1993, 125 infants and children underwent PTFE patch aortoplasty for CoAo; 111 of the procedures were primary repairs, and 14 were reoperations. Diagnoses were isolated CoAo (96 patients), CoAo and ventricular septal defect (15 patients), and CoAo with complex intracardiac anomaly (14 patients). Patient age at the time of repair ranged from 4 days to 17 years (mean age, 5.1±4.5 years). There were no instances of intraoperative mortality or paraplegia. There were 4 deaths from 10 to 40 days postoperatively, all in neonates (mean age, 33 days) who received additional intracardiac procedures for complex associated anomalies. Follow-up has ranged from 6 months to 12.5 years (mean, 4.5±3.2 years). All children had postoperative chest roentgenograms, 80 (66%) patients have had a postoperative echocardiogram and 16 (13%) a cardiac catheterization. One patient had successful repair of a false aneurysm 4 months postoperatively. No patient has developed a late true aneurysm. Of the patients <1 month of age at the time of CoAo repair (12 patients), 6 patients had recurrent CoAo (gradient >20 mm Hg) compared with only 4 recurrences in 97 patients >1 month of age at the time of repair (P<.001).
Conclusions For children >1 year of age, PTFE patch aortoplasty remains our procedure of choice for CoAo repair because of the low mortality rate, low recoarctation rate, and absence of late true aneurysms. We have stopped using this technique for infants <1 month of age because of the high recurrence rate.
Key Words: surgery • pediatrics • coarctation • aorta
|
Introduction |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
The first successful surgical repair of coarctation of the aorta (CoAo) was performed in Stockholm, Sweden, by Crafoord and Nylin in 1944.1 Their patient, a 12-year-old boy, underwent resection of the coarctation segment with end-to-end anastomosis. This resulted in relief of upper-extremity hypertension and normalization of lower-extremity blood pressure. The ensuing years demonstrated that this operation (simple resection with end-to-end anastomosis) was associated with an unacceptably high recoarctation rate, ranging from 20% to 86%.2 3 4
In response to the recoarctation problem, Vossschulte introduced the concept of patch aortoplasty in 1957.5 He initially performed an "isthmusplastic" procedure, which developed into the prosthetic patch angioplasty. This operation had a significantly lower recoarctation rate than resection with end-to-end anastomosis, ranging from 5% to 12%.6 7 8 However, several centers reported the development of true aneurysms in the aortic wall opposite the patch after Dacron patch aortoplasty, particularly when the coarctation ridge was excised.9 10 11
For infants, as an alternative to resection with end-to-end anastomosis, the subclavian flap aortoplasty was first performed by Waldhausen and Nahrwold in 1966.12 This operation also had a higher incidence of recoarctation on long-term follow-up than originally expected.13 14 The recently introduced technique of resection with extended end-to-end anastomosis appears to be associated with good intermediate-term results.15 16 17 However, this technique has been applied essentially only in infants <6 months of age.
The purpose of our review was to evaluate the results of patch aortoplasty for CoAo repair using a relatively new material, polytetrafluoroethylene (PTFE), and an operative technique that does not involve resection of the coarctation ridge. Patients were specifically evaluated for operative mortality and morbidity, recoarctation rate, and incidence of late aneurysm formation.
|
Methods |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Between 1979 and 1993, 125 children had PTFE patch aortoplasty for CoAo at the Children's Memorial Hospital in Chicago, Ill. Diagnoses included isolated CoAo (96 of 125 patients, 76%), CoAo and ventricular septal defect (VSD) (15 of 125 patients, 12%), and CoAo with complex intracardiac anomaly (14 of 125 patients, 11%). Thirty-four patients (27%) had bicuspid aortic valves. Seventy-eight patients were males and 47 were females. Age ranged from 4 days to 17 years (mean age, 5.1±4.5 years). Twelve patients were <30 days of age at the time of repair. During this time there were no specific selection criteria for the operative technique used with patients with CoAo; this was left to the discretion of the individual surgeon for each case. In general, however, most infants <30 days of age underwent subclavian flap aortoplasty in the early part of the series and coarctation resection with extended end-to-end anastomosis later in the series, except, of course, the 12 patients mentioned above who had patch aortoplasty. However, patch aortoplasty was used for nearly all older children (>1 year of age) during the study period. Patch aortoplasty was the first (primary) operation for CoAo in 111 patients and a reoperation for recoarctation in 14 patients. Prior procedures in these patients included subclavian flap aortoplasty (7), resection with end-to-end anastomosis (6), and prior Dacron patch (1).
The technique of PTFE aortoplasty is illustrated in Figs 1
and 2. The PTFE patch material used was
the 0.6-mm-thick Gore-Tex cardiovascular patch (W.L.
Gore & Associates). Careful dissection exposes the transverse aortic
arch, left subclavian artery, ligamentum or ductus arteriosus,
descending aorta, and intercostal collaterals. After proximal and
distal control is obtained with vascular clamps, the aorta is incised
for a distance above and below the CoAo site as indicated by the dashed
line in Fig 1. Heparin is not administered, and the
coarctation ridge is not excised. A PTFE patch is trimmed in an
elliptical fashion and sutured in place with running polypropylene or
PTFE suture (Fig 2). The patch is positioned so that its
widest portion is just at the CoAo site. The patch should be long
enough to extend from the subclavian orifice to the entrance site of
the intercostal collateral arteries. The parietal pleura is then closed
over the patch.
|
|
Recoarctation in this study was defined as a resting gradient >20 mm Hg as measured either by simultaneous arm/leg blood pressure, echocardiogram gradient, or direct measurement at the time of cardiac catheterization.18
|
Results |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
During our study, there was no intraoperative mortality and there were no episodes of postoperative paraplegia. Aortic cross-clamp times were available in 35 patients and ranged from 18 to 40 minutes (mean, 26±6.5 minutes). There were 4 deaths during the perioperative period (10 to 40 days postoperative), all in neonates having associated complex intracardiac procedures early in the series. One child underwent atrioventricular canal repair 2 days after coarctation repair followed by mitral valve replacement 1 week later and died postoperatively. Another child with transposition of the great arteries, VSD, and hypoplastic right ventricle died of sepsis 1 month after cardiac palliation. A third child died 6 weeks after coarctation repair; he had mitral and aortic stenoses; underwent atrial septectomy, aortopulmonary window, and shunt; and died shortly after this procedure. The fourth death occurred in a child with complex transposition of the great arteries who had arterial switch operation 6 days after coarctation repair and died 2 weeks later.
The follow-up time ranges from 6 months to 12.5 years (mean, 4.5±3.2 years). All patients have had postoperative chest roentgenograms and serial blood pressure measurements to assess for recoarctation. Sixty-six percent of the patients had postoperative echocardiograms, and 13% had complete cardiac catheterizations. There was 1 patient who had a false aneurysm noted as an enlargement of the mediastinum on follow-up chest radiography that was successfully repaired with a left thoracotomy by oversewing the suture-line leak 4 months after the initial procedure. No true aneurysms have been detected during the follow-up period.
The incidence of recoarctation after primary PTFE patch aortoplasty was
examined by dividing the patients into two age groups: those <1 month
of age at the time of repair and those >1 month of age at the time of
repair (see Table 1). Mean length of follow-up until
reintervention for recoarctation or until last clinic visit was similar
for these two groups (3.3 years for neonates and 5.0 years for older
children). There were 12 patients <1 month of age at the time of
coarctation repair, and 6 of these patients developed a recoarctation
(a 50% recurrence rate). Recurrence was noted between
4 months and 11 years after the original procedure (median, 7 months).
Two patients underwent reoperation, 2 had percutaneous
transcatheter balloon dilation, and 2 are being followed
with pressure gradients of 28 and 50 mm Hg. For the patients >1 month
of age at the time of primary repair (99 patients), only 4 patients
developed recoarctation (4%). The difference in the recurrence
rate between infants and older children was statistically significant
by Fisher's exact test (P<.001). Of the older patients
with recoarctation, 3 had a gradient in the transverse arch proximal to
the patch. The gradients were first noted 4 to 7 years after surgery
(median, 5 years). Only 1 of these patients has required reoperation.
The other 3 older children are being observed with gradients of 20, 23,
and 25 mm Hg. Clearly the infants with patch aortoplasty developed
recoarctation sooner than older children (7 months versus 5 years
postoperatively) and required more frequent reinterventions (4 of 12
versus 1 of 99 patients). This did not appear to be related to the
length of follow-up available.
|
Fourteen patients underwent patch aortoplasty as a reoperation for recoarctation. There were no deaths in the patients operated on for recoarctation, and only 2 patients have residual gradients (1 25 mm Hg and the other 30 mm Hg) both related to a hypoplastic transverse aortic arch.
|
Discussion |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
Patch aortoplasty using PTFE to augment the CoAo site is a safe and reproducible operation. The mortality rate and incidence of paraplegia after patch aortoplasty are both extremely low. Using PTFE instead of Dacron for the patch and leaving the coarctation ridge intact have resulted in a very low incidence of aneurysm formation. The technique also has a very low recoarctation rate. In our series this technique was applied to essentially all patients >1 year of age at time of coarctation surgery, and it is in these patients that it is most strongly recommended. Because of the high recoarctation rate (50%) in the small number (12) of infants <1 month of age at surgery, the procedure is not recommended for neonates. For patients between 1 month and 1 year of age (17 patients), our data would indicate that this is an efficacious procedure, but it must be remembered that these infants were selected patients in contrast to the children >1 year of age.
Prosthetic patch aortoplasty is a safe operation. The operative
mortality in several series is shown in Tables 2 and
3 and ranges from 0% to
10%.6 7 8 The
technique avoids extensive dissection and prolonged cross-clamp
time that may be required for coarctation resection and
end-to-end anastomosis. Extensive dissection may lead to
intraoperative hemorrhage and prolonged cross-clamp times
to postoperative paraplegia.19 The collateral vessels are
all preserved and do not require ligation or division. The anastomosis
is always tension-free and quite easy to perform. These technical
features of the procedure result in a low mortality and extremely low
incidence of postoperative paraplegia.
|
|
The incidence of recoarctation after patch aortoplasty was quite low in
this review, except in the neonatal group. Recoarctation rates in other
studies using patch aortoplasty are shown in Tables 2
and
3. For older
children and adults, the recoarctation rate ranges from 0% to 16%,
with an average recoarctation rate of 5% in 718 patients. However, as
noted in our patients, the incidence of recurrent coarctation after
patch aortoplasty is higher in neonates. Messmer et al20
reported 8 patients <1 month of age, with 4 of 8 patients (50%)
having recoarctation. The Congenital Heart Surgeons Society's
report21 noted a 21% incidence of recoarctation when this
technique was used in 38 patients <1 month of age. We have abandoned
patch aortoplasty for neonates and instead now use the technique of
coarctation resection with extended end-to-end anastomosis.
Both true and false aneurysms have been reported as complications after every technique of CoAo repair. Aneurysms are also known to occur in patients who did not undergo surgical treatment.22 23 The etiology of aneurysm formation after patch aortoplasty has been attributed to several different factors. The first is resection of the coarctation ridge at the time of aortoplasty with violation of the intimal layer.10 A second contributing factor may be the altered hemodynamics that result from the different tensile strengths of a Dacron patch and the posterior aortic wall, with the pulsatile waveform being completely directed to the posterior aortic wall by the inflexible anterior patch.11 24 Some authors have speculated that there is a congenital abnormality of the aortic wall at the coarctation site.25
The primary theory for the formation of aneurysms relates to the resection of the intimal ridge. In the largest series of patients who have had patch aortoplasty that has been reported, Hehrlein and associates10 noted 18 aneurysms occurring in 317 patients (6%). Of the 14 patients with aneurysm formation for whom detailed information was available, 12 of 14 had an extensive resection of the fibrous coarctation membrane. The authors concluded that resection of this fibrous membrane of the aortic isthmus seemed to be an essential predisposing factor for the development of aneurysms. In 1986, Rheuban and associates11 reported 8 aneurysms in a follow-up of 45 patients who had Dacron patch aortoplasty at a mean age of 8.5 years. In this series, if a significant coarctation ridge was noted, it was excised even though the authors state that this did not increase the incidence of aneurysm formation. Clarkson et al24 reported aneurysm formation in 5 of 38 patients in whom a Dacron patch aortoplasty was performed. In 20 of the 38 patients the intimal ridge was excised. Only 1 patient, however, had a true aneurysm after primary coarctation repair without excision of the intima; 4 patients had false aneurysms. Experimental evidence confirming the role of ridge resection was provided by DeSanto et al,26 who studied Dacron and PTFE patches in dogs with and without concomitant intimal excision opposite the patch. Aneurysms formed in 8 of 12 animals who had intimal excisions and no aneurysms formed in the control animals.
A review of the articles describing aneurysm formation is enlightening and implicates several other factors that may be responsible for aneurysm formation. In 1980, Bergdahl and Ljungqvist27 reported 4 adult patients with aneurysm formation in the aortic wall opposite a Dacron patch. Two of the patients had their patches placed at the time of reoperation after prior resection with end-to-end anastomosis. Del Nido et al28 reported a 5% incidence of aneurysm formation after 63 patch aortoplasties. Two of the 3 patients developing an aneurysm had the patch placed as a repair of recoarctation after primary resection of coarctation with end-to-end anastomosis during infancy. Use of patch aortoplasty as a reoperation after resection with end-to-end anastomosis may increase the risk of aneurysm formation. In our series, 6 patients had prior resection with end-to-end anastomosis; none developed aneurysms.
In 1993, Aebert et al29 reported 14 aneurysms in 56 patients who had had Dacron patch aortoplasty. Patient age at the time of surgery ranged from 14 to 67 years (mean, 28.5 years). These authors felt that an important factor in aneurysm formation was the persistent hypertension present in 59% of their patients after CoAo repair. They concluded that patch aortoplasty repair of CoAo should be abandoned in adults and that adult patients should have interposition of a tubular graft. In the study that reported the highest incidence of aneurysm formation after patch aortoplasty (33%),30 all of the patients were >15 years of age at the time of surgery and ranged up to 54 years of age at the time of operation. The mean patient age at coarctation repair was 25 years. These authors speculated that the reason for the high incidence of aneurysm formation was an abnormality that had developed in the aortic wall over a prolonged period of time because of the patients' advanced ages at the time of surgery. A common theme in these two series is age of the patient (adult) at the time of aortoplasty, which may be a separate risk factor for aneurysms. Adults with long-standing coarctation tend to have an acquired aortic wall weakness and also persistent hypertension after repair. There were no adult patients in our series.
Finally, in most of the above-listed series of patients Dacron was
used as the patch material. The incidence of aneurysm formation
in patients who had Dacron patch aortoplasty appears to be higher
compared with patients who had PTFE for their repairs.29
In the combined totals of patients from Tables 2 and
3, the incidence
of aneurysm formation was 11.9% (70 of 586 patients) after
Dacron patch and 0.3% (1 of 326 patients) after PTFE patch. This is a
significant difference by Pearson's 
2 test
(P<.001). The technical reasons for increased
aneurysm formation with Dacron patches may be related to
stretching and degeneration of the fibers, with subsequent dilatation
of the Dacron.31 32 33 This dilatation
may be more pronounced
in knitted as compared with woven Dacron grafts.34 35
In
contrast, PTFE incites a dense tissue reaction that protects against
aneurysm formation. PTFE does not appear to show any signs of
breakdown via chemical or biological processes over
time.36 37
When the different series reporting aneurysm formation are reviewed, there appear to be several factors that increase the incidence of aneurysm formation after coarctation repair with the patch technique: (1) resection of the coarctation ridge; (2) use of Dacron for the patch material instead of PTFE; (3) use of this procedure in an adult patient; and (4) use of this procedure as a reoperation after resection and end-to-end anastomosis. If these risk factors are avoided, the incidence of aneurysm formation should be extremely low.
Conclusions
PTFE aortoplasty is not indicated for infants
with aortic
coarctation who are <1 month of age because of a high recoarctation
rate. Although our data indicate that PTFE aortoplasty is safe and
effective for children between 1 month and 1 year of age, these were
selected patients. For children who present with aortic coarctation
at >1 year of age, PTFE aortoplasty is our procedure of choice because
it provides excellent relief of coarctation with a very low mortality
rate, a low recoarctation rate, and, in our series, no true
aneurysm formation.
|
Footnotes |
|---|
Reprint requests to Dr Carl L. Backer, Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, 2300 Children's Plaza—M/C #22, Chicago, IL 60614.
|
References |
|---|
|
TopAbstractIntroductionMethods Results Discussion References |
|---|
1. Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Surg. 1945;14:347-361.
2. Hartmann AF Jr, Goldring D, Hernandez A, Behrer MR, Schad N, Ferguson T, Burford T, Crawford C. Recurrent coarctation of the aorta after successful repair in infancy. Am J Cardiol. 1970;25:405-410. [Medline] [Order article via Infotrieve]
3. Williams WG, Shindo G, Trusler GA, Dische MR, Olley PM. Results of repair of coarctation of the aorta during infancy. J Thorac Cardiovasc Surg. 1980;79:603-608. [Abstract]
4.
Kappetein AP, Zwinderman AH, Bogers AJJC, Rohmer J, Huysmans
HA. More than thirty-five years of coarctation repair: an
unexpected high relapse rate. J Thorac Cardiovasc Surg. 1994;107:87-95.
5. Vossschulte K. Isthmusplastik zur Behandlung der Aortenisthmusstenose. Thoraxchirurgie. 1957;4:443-450.
6. Sade RM, Crawford FA, Hohn AR, Riopel DA, Taylor AB. Growth of the aorta after prosthetic patch aortoplasty for coarctation in infants. Ann Thorac Surg. 1984;38:21-25.
7. Yee ES, Soifer SJ, Turley K, Verrier ED, Fishman NH, Ebert PA. Infant coarctation: a spectrum in clinical presentation and treatment. Ann Thorac Surg. 1986;42:488-493. [Abstract]
8. Ungerleider RM. Is there a role for prosthetic patch aortoplasty in the repair of coarctation? Ann Thorac Surg. 1991;52:601-602. Commentary.
9. Ala-Kulju K, Järvinen A, Maamies T, Mattila A, Merikallio E. Late aneurysms after patch aortoplasty for coarctation of the aorta in adults. Thorac Cardiovasc Surg. 1983;31:301-305. [Medline] [Order article via Infotrieve]
10. Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysm after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg. 1986;92:226-230. [Abstract]
11. Rheuban KS, Gutgesell HP, Carpenter MA, Jedeiken R, Damman JF, Kron IL, Wellons J, Nolan SP. Aortic aneurysm after patch angioplasty for aortic isthmic coarctation in childhood. Am J Cardiol. 1986;58:178-180. [Medline] [Order article via Infotrieve]
12. Waldhausen JA, Nahrwold DL. Repair of coarctation of the aorta with a subclavian flap. J Thorac Cardiovasc Surg. 1966;51:532-533. [Medline] [Order article via Infotrieve]
13. Sánchez GR, Balsara RK, Dunn JM, Mehta AV, O'Riordan AC. Recurrent obstruction after subclavian flap repair of coarctation of the aorta in infants. J Thorac Cardiovasc Surg. 1986;91:738-746. [Abstract]
14. Cobanoglu A, Teply JF, Grunkemeier GL, Sunderland CO, Starr A. Coarctation of the aorta in patients younger than three months: a critique of the subclavian flap operation. J Thorac Cardiovasc Surg. 1985;89:128-135. [Abstract]
15. Zannini L, Lecompte Y, Galli R, Gargiulo G, Musiani A, Ghiselli A, Pierangeli A. La coartazione aortica con ipoplasia dell'arco: descrizione di una nuova tecnica chirurgica. G Ital Cardiol. 1985;15:1045-1048. (Abstract in English..) [Medline] [Order article via Infotrieve]
16. Lansman S, Shapiro AJ, Schiller MS, Ritter S, Cooper R, Galla JD, Lowery RC, Golinko R, Ergin MA, Griepp RB. Extended aortic arch anastomoses for repair of coarctation in infancy. Circulation. 1986;74(suppl I):I-37-I-41.
17.
Van Heurn LWE, Wong CM, Spiegelhalter OJ, Sorenson K, DeLeval
MR, Elliott MJ. Surgical treatment of coarctation of aorta in infants
younger than 3 months, 1985-1990: success of extended
end-to-end arch aortoplasty. J Thorac Cardiovasc
Surg. 1994;107:74-86.
18. Kirklin JW, Barratt-Boyes BG. Cardiac Surgery. New York, NY: John Wiley & Sons; 1986:1061.
19. Lerberg DB, Hardesty RL, Siewers RD, Zuberbuhler JR, Bahnson H. Coarctation of the aorta in infants and children: 25 years of experience. Ann Thorac Surg. 1982;33:159-170. [Abstract]
20. Messmer BJ, Minale C, Mühler E, von Bernuth G. Surgical correction of coarctation in early infancy: does surgical technique influence the result? Ann Thorac Surg. 1991;52:594-603. [Abstract]
21.
Quaegebeur JM, Jonas RA, Weinberg AD, Blackstone EH, Kirklin
JW, Congenital Heart Surgeons Society. Outcomes in seriously ill
neonates with coarctation of the aorta: a multiinstitutional study.
J Thorac Cardiovasc Surg. 1994;108:841-854.
22. Reifenstein GH, Levine SA, Gross RE. Coarctation of the aorta: a review of 104 autopsied cases of the adult type. Am Heart J. 1947;33:146-168.
23. Landtman B, Tauteri L. Vascular complications in coarctation of the aorta. Acta Paediatr. 1959;48:329-334. [Medline] [Order article via Infotrieve]
24. Clarkson PM, Brandt PWT, Barratt-Boyes BG, Rutherford JD, Kerr AR, Neutze JM. Prosthetic repair of coarctation of the aorta with particular reference to Dacron onlay patch grafts and late aneurysm formation. Am J Cardiol. 1985;56:342-346. [Medline] [Order article via Infotrieve]
25. Heikkinen L, Sariola H, Salo J, Ala-Kulju K. Morphological and histopathological aspects of aneurysms after patch aortoplasty for coarctation. Ann Thorac Surg. 1990;50:946-948. [Abstract]
26. DeSanto A, Bills RG, King H, Waller B, Brown JW. Pathogenesis of aneurysm formation opposite prosthetic patches used for coarctation repair. J Thorac Cardiovasc Surg. 1987;94:720-723. [Abstract]
27. Bergdahl L, Ljungqvist A. Long-term results after repair of coarctation of the aorta by patch grafting. J Thorac Cardiovasc Surg. 1980;80:177-181. [Abstract]
28. Del Nido PJ, Williams WG, Wilson GJ, Coles JG, Moes CAF, Hosokawa Y, McLaughlin PR, Fowler RS, Izukawa T, Rowe RD, Trusler GA. Synthetic patch angioplasty for repair of coarctation of the aorta: experience with aneurysm formation. Circulation. 1986;74(suppl I):I-32-I-36.
29. Aebert H, Laas J, Bednarski P, Koch U, Prokop M, Borst HG. High incidence of aneurysm formation following patch plasty repair of coarctation. Eur J Cardiothorac Surg. 1993;7:200-205. [Abstract]
30. Ala-Kulju K, Heikkenen L. Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management. Ann Thorac Surg. 1989;47:853-856. [Abstract]
31. Berger K, Sauvage LR. Late fiber deterioration in Dacron arterial grafts. Ann Surg. 1981;193:477-491.[Medline] [Order article via Infotrieve]
32. Watanabe T, Kusaba A, Kuma H, Kina M, Okadome K, Inokuchi K. Failure of Dacron arterial prostheses caused by structural defects. J Cardiovasc Surg. 1983;24:95-100. [Medline] [Order article via Infotrieve]
33. Lundqvist B, Almgren B, Bowald S, Lörelius L-E, Eriksson I. Deterioration and dilatation of Dacron prosthetic grafts. Acta Chir Scand Suppl. 1985;529:81-85. [Medline] [Order article via Infotrieve]
34. Nunn DB, Carter MM, Donohue MT, Hudgins PC. Postoperative dilation of knitted Dacron aortic bifurcation graft. J Vasc Surg. 1990;12:291-297. [Medline] [Order article via Infotrieve]
35. Grennhalgh RM, Chir M. Dilatation and stretching of knitted Dacron grafts associated with failure. In: Bergan JJ, Yao JST, eds. Surgery of the Aorta and Its Body Branches. New York, NY: Grune & Stratton; 1979:621-626.
36. Boyce B. Physical characteristics of expanded polytetrafluoroethylene grafts. In: Stanley JC, ed. Biological and Synthetic Vascular Prostheses. New York, NY: Grune & Stratton; 1982.
37. Sperati CA, Starkweather HW Jr. Fluorine-containing polymers, II: polytetrafluoroethylene. Fortschr Hochpolym-Forsch Bd.. 1961;2:S.465-495.
This article has been cited by other articles:
 |
|
 |
|
  I. M Loftus, K. J Molloy, P. R F Bell, and A R. Naylor Mycotic aortic aneurysm with protective coarctation J R Soc Med, June 1, 2003; 96(6): 291 - 292. [Full Text] [PDF]
|
|
|
|
 |
|
 P. Narasinga Rao, R. N. S. Kumar, D. Anil Kumar, H. M. Mohmoud, S. Chandran, A. K. Dhir, D. K. Saxena, S. P. Azhagappan, V. R. Pillai, C. G. Venkitachalam, et al. Coarctation of the Aorta in Neonates And Young Infants: Surgical Experience Asian Cardiovasc Thorac Ann, December 1, 2002; 10(4): 310 - 313. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S Saunders and C Young An unusual epistaxis Postgrad. Med. J., October 1, 2002; 78(924): 619 - 620. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. L. Backer and C. Mavroudis Congenital Heart Surgery Nomenclature and Database Project: patent ductus arteriosus, coarctation of the aorta, interrupted aortic arch Ann. Thorac. Surg., April 1, 2000; 69(4): S298 - 307. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. L. Backer, C. Mavroudis, E. A. Zias, Z. Amin, and T. J. Weigel Repair of coarctation with resection and extended end-to-end anastomosis Ann. Thorac. Surg., October 1, 1998; 66(4): 1365 - 1370. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. A. Brauner, H. Laks, D. C. Drinkwater Jr, F. Scholl, and S. McCaffery Multiple Left Heart Obstructions (Shone's Anomaly) With Mitral Valve Involvement: Long-Term Surgical Outcome Ann. Thorac. Surg., September 1, 1997; 64(3): 721 - 729. [Abstract] [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||