1. Aortic Coarctation Repair: How I Teach It
Michael E. Mitchell, MD 
The Annals of Thoracic Surgery 
Volume 104, Issue 2, Pages (August 2017)
DOI: /j.athoracsur
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

2. Fig 1
(A) Typical approach with left lateral thoracotomy and third or fourth interspace incision. (B) Anatomy of a typical discrete coarctation with narrowing of the distal aortic isthmus. (C) Intraoperative photograph of representative juxtaductal coarctation with hypoplastic distal transverse arch, left subclavian artery, ligamentum arteriosum, discrete narrowing of distal aortic isthmus, and poststenotic dilation of descending thoracic aorta. (Ao = aorta; IA = isthmus of aorta; LCCA = left common carotid artery; LSCA = left subclavian artery; PDA = patent ductus arteriosus.)
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

3. Fig 2
(A) Ligation and surgical division of patent ductus arteriosus. (B) Intraoperative photograph of division of ductus arteriosus.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

4. Fig 3
(A) Application of clamp on arch of aorta, left common carotid, and left subclavian vessels. Dotted lines indicate planned resection of the coarctation segment including oblique incision onto the undersurface of the aortic arch. (B) Incision on the undersurface of the arch of the aorta, and posterolateral cutback on the descending aorta. Three intercostals are illustrated as previously divided. (C) Intraoperative photograph of the application of proximal clamp including left common carotid and left subclavian with traction applied to the lateral wall.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

5. Fig 4
(A) Creation of interdigitating incisions with fillet on undersurface of aortic arch, posterolateral cutback on descending aorta, and cuts made anteriorly and posteriorly from the cut undersurface of the arch toward the base of the left subclavian artery. (B) Intraoperative photo of fillet on the undersurface of aortic arch to just beyond the os of the left common carotid artery. (C) Posterolateral cutback looking down the descending thoracic aorta. (D) After creating the anterior cut, the creation of the posterior cut from the undersurface of the aortic arch to the base of the left subclavian artery.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

6. Fig 5
(A) Construction of the interdigitated anastomosis starting at the toe and working toward the heel. The corners of the descending aorta interdigitate into the cuts made toward the base of the left subclavian artery. (B) Intraoperative photograph of the posterior suture line approaching the interdigitating sutures that bring the corner of the posterior wall of the descending aorta into the interdigitated cut.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

7. Fig 6
(A) The completed suture line. Note the noncircular anastomosis. (B) Posterior view of suture line illustrating depth of posterolateral interdigitation. (C) Intraoperative photograph of completed repair. Note that the suture line becomes the widest part of the distal aortic arch.
The Annals of Thoracic Surgery  , DOI: ( /j.athoracsur )
Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions