If there are no complicating comorbidities or anatomic considerations (e.g. RAA), a coarctation resection (i.e. coarctectomy) is often performed without cardiopulmonary bypass via lateral thoracotomy.  The transverse aorta is cross-clamped with care to ensure antegrade blood flow into all of the brachiocephalic arteries.  The coarctation is resected entirely with the ductus, which is ligated and divided on the pulmonary end.  At times the left subclavian artery is ligated and divided to help mobilize the aorta to decrease tension on the suture line.  Rarely, the left subclavian can be used as a flap to augment the aortic isthmus.  Generally, the aorta is cross-clamped for 15-30 minutes for the procedure, which takes place at ~33-35°C (ambient cooling only).  Blood flow to the brain is antegrade, to the spinal cord is through vertebral and intercostal arteries.  Postoperative gradient is assessed by echo, and often by comparison of a right radial arterial line with lower extremity cuff BP.  Four extremity BPs should be performed postoperatively on a regular basis particularly in patients who are not doing as expected.  Rarely, residual ductal tissue may cause a recurrent coarctation.  Injury to the thoracic duct, recurrent laryngeal nerve (vocal cord function), and vagus nerve are possible and should be monitored for.