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Anterior Aortopexy for Tracheomalacia

  • Martin J. Elliott
    Affiliations
    The National Service for Severe Tracheal Disease in Children, The Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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  • Simone Speggiorin
    Affiliations
    The National Service for Severe Tracheal Disease in Children, The Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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  • Michele Torre
    Correspondence
    Address reprint requests to: Michele Torre, MD, The Tracheal Service, The Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK
    Affiliations
    The National Service for Severe Tracheal Disease in Children, The Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom

    Pediatric Surgery, Istituto G. Gaslini, Genova, Italy
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      Tracheomalacia (TM) is a localized or generalized weakness of the tracheal wall, which creates airway obstruction, resulting in different degrees of possible respiratory symptoms. It can be isolated or associated with other anomalies such as anterior vascular compression, esophageal atresia with tracheoesophageal fistula (TOF), or gastroesophageal reflux. Although in some cases spontaneous improvement can occur, TM can lead to severe cough, respiratory distress episodes, or “near-death” spells (acute life-threatening events).
      Among the preoperative investigations, fiberoptic bronchoschopy (FOB) plays the main role. In our institution, FOB is used with bronchography to additionally assess the dynamics of the trachea during the respiratory phases, providing quantitative measures of the airway and dynamic information regarding opening pressures.
      • Mok Q.
      • Negus S.
      • McLaren C.A.
      • et al.
      Computed tomography versus bronchography in the diagnosis and management of tracheobronchomalacia in ventilator dependent infants.
      In most cases, a computerized tomography scan is useful to study the relationship between cardiovascular and airway anatomy and to help define the best treatment. Treatment relates to the severity of symptoms and can vary from a conservative approach awaiting spontaneous improvement to airway stenting or aortopexy.
      Aortopexy has been demonstrated to be effective in treating most cases of TM.
      • Calkoen E.E.
      • Gabra H.O.
      • Roebuck D.J.
      • et al.
      Aortopexy as treatment for tracheo-bronchomalacia: An 18-year single-center experience.
      Its rationale is to bring the vascular structures away from the airways toward the sternum. Depending on the type of TM, different technical solutions can be adopted. If malacia is secondary to vascular compression, the pretracheal fascia is dissected from the posterior aspect of the aorta and innominate artery, creating a free space and relieving the compression on the airway. Second, in the presence of posterior collapse of the tracheal wall, mainly associated with TOF, or after fetal endotracheal occlusion,
      • Speggiorin S.
      • Fierens A.
      • McHugh K.
      • et al.
      Bronchomegaly as a complication of fetal endoscopic tracheal occlusion A caution and a possible solution.
      the pretracheal fascia is left intact to allow the anterior tracheal wall to be pulled forward with the aorta, thus enlarging the airway lumen by increasing the anteroposterior tracheal diameter.
      Many approaches for aortopexy have been proposed: left anterior thoracotomy,
      • Kiely E.M.
      • Spitz L.
      • Brereton R.
      Management of tracheomalacia by aortopexy.
      muscle sparing left thoracotomy,
      • Dave S.
      • Currie B.G.
      The role of aortopexy in severe tracheomalacia.
      right thoracotomy,
      • Kamata S.
      • Usui N.
      • Sawai T.
      • et al.
      Pexis of great vessels for patients with tracheobronchomalacia in infancy.
      median sternotomy,
      • Cohen D.
      Tracheopexy-aorto-tracheal suspension for severe tracheomalacia.
      • Brawn W.J.
      • Huddart S.N.
      Tracheoaortopexy via midline sternotomy in tracheomalacia.
      and a thoracoscopic approach from either the left or the right side.
      • Schaarschmidt K.
      • Kolberg-Schwerdt A.
      • Pietsch L.
      • et al.
      Thoracoscopic aortopericardiosternopexy for severe tracheomalacia in toddlers.
      • Perger L.
      • Kim H.B.
      • Jaksic T.
      • et al.
      Thoracoscopic aortopexy for treatment of tracheomalacia in infants and children.
      • Kane T.D.
      • Nadler E.P.
      • Potoka D.A.
      Thoracoscopic aortopexy for vascular compression of the trachea: Approach from the right.
      • Durkin E.T.
      • Krawiec M.E.
      • Shaaban A.F.
      Thoracoscopic aortopexy for primary tracheomalacia in a 12-year-old.
      • Van der Zee D.C.
      • Bax N.M.
      Thoracoscopic tracheoaortopexia for the treatment of life-threatening events in tracheomalacia.
      All have advantages, but our routine approach is through a limited superior sternotomy, because it gives excellent exposure and easy access to the superoanterior mediastinum and pretracheal fascia, as well as safe control of the aortic arch in case of complications. Moreover, it is suitable for all morphologic variants.

      Operative Technique

      Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11
      Figure thumbnail gr1
      Figure 1Median incision. The upper sternal edge, angle of Louis, xyphisternum, and the sternal midline are marked on the skin. The skin incision is performed from the upper sternum to the angle of Louis. This corresponds to the junction between the second rib cartilage and the sternum. The incision is deepened into the anterior sternal plate, taking care to stay exactly in the midline. The sternum is then grasped and lifted up to avoid damage to vascular structures during sternotomy. A blind dissection of the retrosternal space is performed by inserting a dissector below the sternal posterior plate. An oscillating saw is used to perform an upper sternotomy. Some homeostasis of the 2 sternal edges is usually necessary. A small spreader is then inserted between the 2 sternal halves.
      Figure thumbnail gr2
      Figure 2Thymectomy. The left or both thymic lobes are removed by careful dissection of the thymic capsule. Particular attention must be taken to avoid the phrenic nerves, which lie on the lateral aspect of the thymic capsule, and not to open the pleurae. Dissection can be performed by either diathermy or blunt dissection, taking care not to injure the brachiocephalic vein, which lies just deep to the thymus.
      Figure thumbnail gr3
      Figure 3Medial dissection to the pretracheal space. The trachea is identified by direct digital palpation; the dissection of the anterior mediastinum is performed in the midline and is deepened to the pretracheal space. The innominate artery and vein are exposed. Ao = aorta; SVC = superior vena cava.
      Figure thumbnail gr4
      Figure 4The trachea appears in the midline deep to these structures and is easily identified by its cartilage hoops. If required, the pretracheal space is dissected as the space between the trachea and the brachiocephalic artery. This is done by inserting a blunt right-angle dissector along the anterior tracheal wall down to the carina, underneath the brachiocephalic and pulmonary arteries.
      Figure thumbnail gr5
      Figure 5Pericardium opening and stay sutures. Although we prefer to open the pericardium, other surgeons prefer not to. The pericardium is incised over the ascending aorta at the origin of the brachiocephalic artery. Pericardial stay sutures are passed (2 or 3 on each side) and fixed bilaterally by Kelly clamps.
      Figure thumbnail gr6
      Figure 6Stitches to the aorta and pericardial reflection. Two 3-0 or 4-0 double-needle Prolene “U” stitches reinforced with Teflon pledgets are passed into the aortic wall at the origin of the innominate artery, and through the pericardial edges at the level of the pericardial reflection. The stitches are passed on each side of the aorta just proximal to the innominate artery, and deep enough inside the aortic wall not to tear it, but not entering the lumen. The sutures are started posteriorly so that pledgets remain parallel to the long axis of the aorta. Usually 2 stitches are sufficient.
      Figure thumbnail gr7
      Figure 7Pericardial drain. A small Redivac drain is left inside the pericardium, with some holes draining the mediastinal space as well. The drain is secured to the skin by a nonabsorbable suture. This step is avoided if the pericardium has not been opened.
      Figure thumbnail gr8
      Figure 8Stitches through sternum. Both needles of each “U” stitch are passed inside out through the each half of the sternum, at the most convenient point (on the right or left side) to obtain effective lifting of the aortic arch. This can be monitored by simultaneous FOB. These stitches are kept in place with a rubber clamp without tying them.
      Figure thumbnail gr9
      Figure 9Sternal closure. The sternum is closed with multiple 0 Vicryl stitches.
      Figure thumbnail gr10
      Figure 10Aortopexy stitches tie down. An external additional Teflon pledged is positioned and the sutures are gently tied on the anterior surface of the sternum. The suture must be neither too tight to avoid tearing of the aortic wall nor too loose, resulting in residual vascular compression of the airway. FOB helps to monitor the enlargement of the airway lumen.
      Figure thumbnail gr11
      Figure 11Soft tissue closure. The muscles are approximated on the midline. The subcutaneous layer and skin are sutured with continuous Monocryl 5-0 suture.

      Conclusions

      Perioperative bronchoscopy can be performed to demonstrate the improvement of the tracheobronchial lumen. The pericardial drain is removed after 24 hours. Usually the patients are easily extubated in theater or shortly afterward and are expected to have a short and easily manageable postoperative hospitalization. Complications are rare, although pericarditis, pneumonia, bleeding, chylothorax, or phrenic or recurrent nerve lesions have been observed. Pericardial effusion is the most common one and may be life-threatening; thus, we prefer to perform echocardiography 2 to 3 weeks post surgery. Our experience indicates that the results of aortopexy relate to the group of patients with TM.
      • Calkoen E.E.
      • Gabra H.O.
      • Roebuck D.J.
      • et al.
      Aortopexy as treatment for tracheo-bronchomalacia: An 18-year single-center experience.
      Patients with congenital TM, associated with TOF (group 1) or vascular compression (group 2), have better outcomes than patients with acquired TM, usually associated with other comorbidities, mainly cardiac anomalies (group 3). In the latter group we have observed an increased risk of mortality (9% overall), failure of the aortopexy and need for a redo surgery (4%), of stenting failure (5%), or a tracheostomy insertion/decannulation failure (9%).
      • Calkoen E.E.
      • Gabra H.O.
      • Roebuck D.J.
      • et al.
      Aortopexy as treatment for tracheo-bronchomalacia: An 18-year single-center experience.
      The quality-of-life results have been excellent after a mean follow-up of 7 years in 73% of all patients, but we have observed a significant difference among groups, as 80% of the patients in groups 1 and 2 reported excellent results, compared with only 57% of group 3.
      • Calkoen E.E.
      • Gabra H.O.
      • Roebuck D.J.
      • et al.
      Aortopexy as treatment for tracheo-bronchomalacia: An 18-year single-center experience.
      Other alternative approaches for aortopexy have been described in the literature, including left or right thoracotomy,
      • Kiely E.M.
      • Spitz L.
      • Brereton R.
      Management of tracheomalacia by aortopexy.
      • Dave S.
      • Currie B.G.
      The role of aortopexy in severe tracheomalacia.
      • Kamata S.
      • Usui N.
      • Sawai T.
      • et al.
      Pexis of great vessels for patients with tracheobronchomalacia in infancy.
      complete sternotomy,
      • Cohen D.
      Tracheopexy-aorto-tracheal suspension for severe tracheomalacia.
      • Brawn W.J.
      • Huddart S.N.
      Tracheoaortopexy via midline sternotomy in tracheomalacia.
      or a thoracoscopic approach,
      • Schaarschmidt K.
      • Kolberg-Schwerdt A.
      • Pietsch L.
      • et al.
      Thoracoscopic aortopericardiosternopexy for severe tracheomalacia in toddlers.
      • Perger L.
      • Kim H.B.
      • Jaksic T.
      • et al.
      Thoracoscopic aortopexy for treatment of tracheomalacia in infants and children.
      • Kane T.D.
      • Nadler E.P.
      • Potoka D.A.
      Thoracoscopic aortopexy for vascular compression of the trachea: Approach from the right.
      • Durkin E.T.
      • Krawiec M.E.
      • Shaaban A.F.
      Thoracoscopic aortopexy for primary tracheomalacia in a 12-year-old.
      • Van der Zee D.C.
      • Bax N.M.
      Thoracoscopic tracheoaortopexia for the treatment of life-threatening events in tracheomalacia.
      but there is no evidence for a better outcome with any of them, as no randomized studies exist to compare the different techniques.
      • Masters I.B.
      • Chang A.B.
      Interventions for primary (intrinsic) tracheomalacia in children.

      References

        • Mok Q.
        • Negus S.
        • McLaren C.A.
        • et al.
        Computed tomography versus bronchography in the diagnosis and management of tracheobronchomalacia in ventilator dependent infants.
        Arch Dis Child Fetal Neonatal. 2005; 90: F290-F293
        • Calkoen E.E.
        • Gabra H.O.
        • Roebuck D.J.
        • et al.
        Aortopexy as treatment for tracheo-bronchomalacia: An 18-year single-center experience.
        Pediatr Crit Care Med. 2011 Jan 21; (Epub ahead of print)
        • Speggiorin S.
        • Fierens A.
        • McHugh K.
        • et al.
        Bronchomegaly as a complication of fetal endoscopic tracheal occlusion.
        J Pediatr Surg. 2011; 45: e1-e3
        • Kiely E.M.
        • Spitz L.
        • Brereton R.
        Management of tracheomalacia by aortopexy.
        Pediatr Surg Int. 1987; 2: 13-15
        • Dave S.
        • Currie B.G.
        The role of aortopexy in severe tracheomalacia.
        J Pediatr Surg. 2006; 41: 533-537
        • Kamata S.
        • Usui N.
        • Sawai T.
        • et al.
        Pexis of great vessels for patients with tracheobronchomalacia in infancy.
        J Pediatr Surg. 2000; 35: 454-457
        • Cohen D.
        Tracheopexy-aorto-tracheal suspension for severe tracheomalacia.
        Aust Paediatr J. 1981; 17: 117-121
        • Brawn W.J.
        • Huddart S.N.
        Tracheoaortopexy via midline sternotomy in tracheomalacia.
        J Pediatr Surg. 1991; 26: 660-662
        • Schaarschmidt K.
        • Kolberg-Schwerdt A.
        • Pietsch L.
        • et al.
        Thoracoscopic aortopericardiosternopexy for severe tracheomalacia in toddlers.
        J Pediatr Surg. 2002; 37: 1476-1478
        • Perger L.
        • Kim H.B.
        • Jaksic T.
        • et al.
        Thoracoscopic aortopexy for treatment of tracheomalacia in infants and children.
        J Laparosc Adv Surg Techn. 2009; 19: S249-S254
        • Kane T.D.
        • Nadler E.P.
        • Potoka D.A.
        Thoracoscopic aortopexy for vascular compression of the trachea: Approach from the right.
        J Laparosc Adv Surg Techn. 2008; 18: 313-316
        • Durkin E.T.
        • Krawiec M.E.
        • Shaaban A.F.
        Thoracoscopic aortopexy for primary tracheomalacia in a 12-year-old.
        J Pediatr Surg. 2007; 42: E15-E17
        • Van der Zee D.C.
        • Bax N.M.
        Thoracoscopic tracheoaortopexia for the treatment of life-threatening events in tracheomalacia.
        Surg Endosc. 2007; 21: 2024-2025
        • Masters I.B.
        • Chang A.B.
        Interventions for primary (intrinsic) tracheomalacia in children.
        Cochrane Database Syst Rev. 2005; 19 (CD005304)