Abstract:
Objectives: Innominate artery compression syndrome (IAS) is caused by an anterior compression of the trachea by an abnormally originating innominate artery. One option to relieve such a compression is an anterior aortopexy (AA). In this paper we describe our technique of an AA via a partial upper median sternotomy.
Methods : A retrospective review of a prospectively maintained database of patients with IAS (July 2017 to November 2020) treated with AA via a partial upper median sternotomy at University teaching hospitals in the US was done.
Results : Nine consecutive patients underwent AA for IAS during the study period. The median age was 9 months (IQR 3- 16.5). The male to female ratio was 1.25. All patients had > 70% compression by flexible bronchoscopy. 2 patients had previous surgeries. The follow-up was a median of 6 (IQR 4- 8.5) months. The indications for the operation were: reflex apnea (4/9 patients), recurrent intubation (4/9 patients), and severe stridor (1/9). IAS was a technical success (defined as ≤ 20 % residual stenosis) in 78 % (7/9) of the patients. Complete symptom resolution after an AA was seen in 71% (5/7) of the patients. 2 patients had an unsuccessful AA, requiring a tracheal resection and an innominate artery reimplantation, respectively.
Conclusion : An upper partial sternotomy approach provides a very versatile approach to an AA for IAS. Besides facilitating an adequate AA, it provides options for direct tracheal surgery or an innominate artery reimplantation in case an optimal result is not obtained by an AA.
Introduction: Anterior aortopexy (AA) for Innominate Artery compression Syndrome (IAS) was first described by Gross in 1948[1]. The procedure was performed by a left anterior thoracotomy. Since then, several approaches to perform an AA have been described such as a right thoracotomy, a median sternotomy, a partial upper sternotomy and even a thoracoscopic approach [4, 6]. A partial upper sternotomy approach for AA for tracheomalacia from all causes has been previously described by Elliot [6]. This approach has become our preferred approach for an AA for IAS. In this paper, we illustrate our technique and describe the experience gained from 9 consecutive cases performed from 2018 to 2020 using an upper partial median sternotomy approach to an AA specifically for an IAS.
Methods: The study is a retrospective review of a prospectively maintained database of nine consecutive patients with IAS treated by AA from July 2017 to November 2020. The patients were operated by two surgeons at the University of Pittsburgh (SS- Sandeep Sainathan), University of Tennessee Health Sciences Center (SS), University of North Carolina at Chapel Hill (SS) and Mount Sinai Hospital in New York (RM- Raghav Murthy). No other approach to an AA was attempted by the above surgeons to act as comparator. The study is a retrospective review of a prospectively maintained de-identified database. No further chart-review or any form of patient contact was attempted for this study and hence is IRB exempt. The study was not part of any research protocol and written informed consent was obtained for the operative procedures. No portions of the manuscript and the submitted pictures have any information that can lead to identification of the patient as per the Healthcare Insurance Portability and Accountability ACT of (HIPAA) 1996.
All the cases were referred either by pediatric cardiology or by pediatric pulmonology. Besides a detailed history and through physical exam, the work-up included an airway evaluation either with a flexible bronchoscopy or a rigid bronchoscopy (Figure 1 ) and a cross-sectional imaging either in the form of a computed tomography or MRI (Figure 2 ). The cases were discussed in a multidisciplinary case conference involving cardiac surgery, pediatric cardiology, pediatric pulmonology and pediatric otolaryngology. Surgery was offered when there was at least 70% tracheal stenosis at bronchoscopy from anterior tracheal compression by the innominate artery with associated symptoms. Technical success was defined ≤20% residual stenosis after AA.
The data was abstracted for demographic information, clinical characteristics, operative intervention, complications and follow-up. Follow-up was the last documented clinic visit in the database. Given the sample size, only descriptive statistics were used.
Surgical Technique : The procedure is performed under general anesthesia with a single lumen endotracheal tube. A radial arterial line is used for hemodynamic monitoring. Venous access is generally peripheral. A flexible bronchoscopy is performed to assess the severity of the tracheal compression and also ensures that the endotracheal tube is positioned proximal to the area of the compression (Figure 1 ). It is critical to have an adequate extension of the neck with a shoulder roll in order to facilitate a partial upper sternotomy. This is particularly important in infants as they tend to have very short necks. The lower face, neck and the entire anterior chest is prepped and draped in a standard sterile fashion. Prophylactic antibiotics are used.
The procedure is started with a partial upper median sternotomy to the third intercostal space. A Diethrich sternal saw is used to divide the sternum after the suprasternal space is adequately developed by dividing the interclavicular ligament and bluntly dissecting the retrosternal space. Given the flexibility of the sternum in children, only a central split of the manubrium and the upper sternal body is necessary without any need for a T incision of the sternal body (Figure 3 ).