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 ).