. (1975). Thorax, 30,[31][32][33][34][35][36][37][38][39]. Late complications of surgery for coarctation of the aorta. The problem of the patient who has had one operation for coarctation of the aorta and who then requires another because of a late complication at or near the coarctation site is a demanding one. The safety of aortic cross-clamping at the second operation depends on the adequacy or otherwise of the collateral circulation, and this in turn depends on the presence or absence of residual or recurrent aortic obstruction. Three illustrative cases are described in which there was complete, incomplete, and no aortic obstruction respectively at the time of reoperation, two of the cases presenting the additional complication of local aneurysm formation. The various aspects of management of such individuals are discussed, and the relevant literature has been reviewed in an attempt to provide a systematic approach to these difficult patients.The methods for assessing collateral circulation are both clinical and radiological with trial clamping of the aorta and pressure measurement as the most reliable ultimate test. A pressure of 50 mmHg in the distal aorta is accepted as indicating an adequate peripheral circulation, but it is recommended that the trial clamping should always include both the left subclavian artery and any particularly large local collaterals. The use of a perfusion technique to sustain the distal tissues is also recommended, although local bypass shunts have a place when their use is dictated in the interests of safety for the patient.From the early days of coarctation surgery late complications have been recognized and recorded (Owens and Swan, 1963). These have been related to infection (Martin, Kirklin, and DuShane, 1956;Roesch and Bond, 1960;Oldham et al., 1973), unfavourable anatomy, inadequacies of technique, and, in small children, the problem of growth failure at the suture line (Parsons and Astley, 1966).The question of late reoperation is often not an easy one and the second operation itself can be difficult and dangerous. Apart from the local hazards in the region of the previous repair, which can include aneurysm formation, dense adhesion to surrounding structures, and abnormal thinning of the aortic wall (Cerilli and Lauridsen, 1965), the most serious risk in reoperation is that of spinal cord damage and consequent paralysis (Brewer et al., 1972). This risk is related to the efficiency of the collateral circulation when the aorta is clamped or to the efficiency of the method 31 chosen to protect the distal tissues when aortic blood flow is interrupted. The state of the collateral circulation itself at the time of the second operation reflects the presence or absence of residual or recurrent aortic obstruction and its duration and degree when present.This communication describes the problem presented by three patients, all requiring late second operation, who had respectively total, partial, and no obstruction to the aortic lumen at the time of their reoperation. The three pa...

Objectives & BackgroundResuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) aims to improve trauma survival by controlling torso haemorrhage. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative technique that, in addition to controlling torso haemorrhage, allows infusion of oxygenated blood into the proximal aorta - theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation (ROSC) in cardiac arrest (figure 1). Prolonged cardiac support can subsequently be achieved by converting the SAAP blood supply from exogenous to autologous via a central venous catheter–an extra-corporeal life support circuit (SAAP-ECLS).Hypotheses–1. Swine in haemorrhage-induced traumatic cardiac arrest that do not achieve a ROSC with initial therapy (REBOA), will have ROSC with more advanced therapy (SAAP). 2. Animals that do not achieve ROSC with REBOA and subsequent SAAP will achieve ROSC with SAAP-ECLS.Methods70–90 kg swine underwent a combination of non-compressible torso and arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) <10 mm Hg, together with an inappropriate bradycardia. All animals initially received REBOA (inflation of zone 1 REBOA and four units of intravenous blood). Those that did not achieve ROSC (defined as SBP >50 mm Hg) subsequently received SAAP (800 ml/minute of intra-aortic oxygenated blood, up to 4000 ml). Animals that did not have a ROSC after SAAP received continuous SAAP-ECLS (at 800 ml/minute). The protocol end-point was 60 minutes from the start of the REBOA intervention. Data are descriptive, and presented as mean (+/−standard deviation) and number (percent).ResultsEight animals were included; weight 75.0 kg (+/−3.6); time from the start of the injury to onset of arrest was 9.9 minutes (+/−1.4). Two (25.0%) animals had a ROSC with REBOA, and out of the remaining six a further two (25.0%) had a ROSC with SAAP. The four remaining animals, that had not achieved ROSC with REBOA and subsequent SAAP, all had a ROSC with SAAP-ECLS (figure 2).ConclusionA step-wise approach of more complex endovascular intervention in haemorrhage-induced traumatic cardiac arrest may be an effective clinical paradigm – in this swine model all animals had short-term survival following escalating intervention: REBOA, followed by SAAP, followed SAAP-ECLS as required.Figure 1Figure 2

Objectives & BackgroundHaemorrhage is the leading cause of potentially survivable trauma death. Selective Aortic Arch Perfusion (SAAP) is an experimental resuscitative intervention that has the potential to improve trauma survival: a trans-femoral intra-aortic balloon controls torso haemorrhage, while the catheter's large central lumen allows oxygenated blood to be delivered to the proximal aorta–theoretically providing coronary perfusion pressures adequate for return of spontaneous circulation in cardiac arrest (figure 1).Hypothesis–In haemorrhage-induced traumatic cardiac arrest, SAAP with oxygenated blood will infer a short-term survival advantage over both closed chest compressions (CPR) with intravenous blood, and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with intravenous blood.Methods70–90 kg swine underwent a non-compressible torso haemorrhage (NCTH) and controlled arterial haemorrhage. Arrest was defined as a systolic blood pressure (SBP) <10 mm Hg, together with an inappropriate bradycardia. Animals were allocated to one of three groups: CPR with four units of intravenous blood, REBOA with four units of intravenous blood, and fresh whole blood SAAP (FWB-SAAP) with 1600 ml of oxygenated intra-aortic blood. Primary outcome was 60-minute ‘pre-hospital’ survival. Data are described as mean (+/− standard devation). Multi-group analyses were by ANOVA, and survival was analysed by Log-rank (Mantel-Cox) test.ResultsThere were ten animals per group, a total of 30 swine. Mean weight of 79.9 kg (+/−5.5) p=0.3. Mean time from the start of the injury to onset of arrest was 11.2 minutes (+/−1.9) p=0.2. Prior to intervention the mean SBP was 2.9 mm Hg (+/−3.2) p=0.7, and the mean heart rate was 41 bpm (+/−32) p=0.5.Primary outcome – FWB-SAAP demonstrated an 80% 60-minute ‘pre-hospital’ survival, compared to 10% with CPR, and 0% with REBOA, p<0.001 (figure 2).ConclusionIn this swine model of haemorrhage-induced traumatic cardiac arrest with NCTH, SAAP infers a short-term survival advantage over both conventional therapy (CPR), and over evolving therapy (REBOA). Of note, SAAP induced return of spontaneous circulation from cardiac electrical asystole.Figure 1Figure 2