Figure 7 : Partial sternotomy incision after closure with a Blake drain draining the mediastinal and pericardial space and exiting inferior to the xiphoid process.
Results: A total of 9 patients underwent AA for IAS from 2017 to 2020 (Table 1). The median age was 9 months (IQR 3- 16.5). The male to female ratio was 1.25 (5/4 patients). The aortic arch was left sided in 89% (8/9) patients. 2 patients had chromosomal abnormalities (one each with Trisomy 21 and 18). All patients had > 70% compression by flexible bronchoscopy. 2 patients had previous surgeries. One patient had a double aortic arch with an atretic left arch which was divided previously via left thoracotomy and the other patient had a trachea-esophageal fistula which was previously repaired via right thoracotomy. The follow-up was a median of 6 (IQR 4- 8.5) months. The indications for the operation were: reflex apnea 44% (4/9 patients), recurrent intubation 44% (4/9 patients), and severe stridor 11% (1/9). IAS was a technical success (defined ≤ 20% residual stenosis) in 78 % of the patients (7/9 patients). Complete symptom resolution after an AA was seen 71% of the patients (5/7 patients) with technical success. Of the two patients who had incomplete symptom resolution despite a technical success, one patient had a 20% residual stenosis with mild stridor but has not had any further episodes of reflex apnea. The other patient with 15% residual stenosis had mild residual stridor but also had an associated glottic pathology. AA was unsuccessful in 2 patients with an initial attempted procedure producing 50% residual stenosis. One patient had an associated intrinsic tracheal stenosis from isolated tracheal cartilage deficiency which was not diagnosed preoperatively and was treated with a tracheal resection and anastomosis using cardiopulmonary bypass. The other patient had an innominate artery arising very leftward along the aortic arch and needed a re-implantation of the innominate artery rightward of the trachea in a more normal position. Interestingly, this patient also had a right sided upper partial anomalous pulmonary venous return needing a Warden repair. Both had an excellent result after the above described procedures. There were no wound infections, phrenic nerve palsy, pericardial or pleural effusion in the patients. One patient needed a repeat full sternotomy 6 months after the AA to repair a complete atrioventricular canal defect at 8 months of age.