Aortopexy in Infants and Children—Long-term Follow-up in Twenty Patients

Surgical treatment for severe pediatric tracheobronchomalacia: the 20-year experience of a single center

OBJECTIVE

In children with tracheobronchomalacia, surgical management should be reserved for the most severe cases and be specific to the type and location of tracheobronchomalacia. The goal of this study is to describe the presentation and outcomes of children with severe tracheobronchomalacia undergoing surgery.

METHODS

Retrospective case series of 20 children operated for severe tracheobronchomalacia at a tertiary hospital from 2003 to 2023. Data were collected on symptoms age at diagnosis, associated comorbidities, previous surgery, age at surgery, operative approach, time of follow-up, and outcome. Surgical success was defined as symptom improvement.

RESULTS

The most frequent symptoms of severe tracheobronchomalacia were stridor (50 %), cyanosis (50 %), and recurrent respiratory infections (45 %). All patients had one or more underlying conditions, most commonly esophageal atresia (40 %) and prematurity (35 %). Bronchoscopy were performed in all patients. Based on etiology, patients underwent the following procedures: anterior aortopexy (n = 15/75 %), posterior tracheopexy (n = 4/20 %), and/or posterior descending aortopexy (n = 4/20 %). Three patients underwent anterior aortopexy and posterior tracheopexy procedures. After a median follow-up of 12 months, 16 patients (80 %) had improvement in respiratory symptoms. Decannulation was achieved in three (37.5 %) out of eight patients with previous tracheotomy. The presence of dying spells at diagnosis was associated with surgical failure.

CONCLUSIONS

Isolated or combined surgical procedures improved respiratory symptoms in 80 % of children with severe tracheobronchomalacia. The choice of procedure should be individualized and guided by etiology: anterior aortopexy for anterior compression, posterior tracheopexy for membranous intrusion, and posterior descending aortopexy for left bronchus obstruction.

Role of aortopexy in the treatment of aberrant innominate artery in children

PURPOSE

The aim of this study was to assess the surgical and follow-up outcomes in children who operated for aberrant innominate artery.

METHODS

A total of 15 consecutive patients (12 males, 3 females; mean age 16.3 ± 19.0 months; range 3 months to 6 years) who underwent aortopexy between February 2018 and December 2021 were evaluated. Demographic data, preoperative and postoperative clinical status and postoperative outcomes were retrospectively analyzed.

RESULTS

The mean age at operation was 16.3 ± 19.0 months. The median weight was 8.3 kg (range, 7-14.5 kg).There was no complications at intraoperative period. The mean percent degree of tracheal stenosis was 0.68 ± 0.12. The median (range) MV duration, PICU stay, and ward stay of the patients were 2 h (0-3 h), 2.5 days (1-4 days), and 5 days (3-8 days), respectively. The mean patients' number of emergency service applications and hospitalization at the preoperative period was 6.2 ± 3.9/2.3 ± 1.6 and, at the postoperative period was 3.3 ± 2.2/0.9 ± 0.8. In comparison of the preoperative and postoperative service application number and hospitalization number, there was significant difference (p < 0.005 and 0.006, respectively). No reoperation was required. There was no mortality.

CONCLUSION

Aberrant innominate artery is rarely seen. These pathologies misdiagnosis with different reactive airways. Following the diagnosis, treatment can be achieved by surgery successfully.

Pulmonary function of children with tracheomalacia and associated clinical factors

OBJECTIVES

Spirometry is easily accessible yet there is limited data in children with tracheomalacia. Availability of such data may inform clinical practice. We aimed to describe spirometry indices of children with tracheomalacia, including Empey index and flow-volume curve pattern, and determine whether these indices relate with bronchoscopic features.

METHODS

From the database of children with tracheomalacia diagnosed during 2016-2019, we reviewed their flexible bronchoscopy and spirometry data in a blinded manner. We specially evaluated several spirometry indices and tracheomalacia features (cross-sectional lumen reduction, malacic length, and presence of bronchomalacia) and determined their association using multivariable regression.

RESULTS

Of 53 children with tracheomalacia, the mean (SD) peak expiratory flow (PEF) was below the normal range [68.9 percent of predicted value (23.08)]. However, all other spirometry parameters were within normal range [Z-score forced expired volume in 1 s (FEV₁ ) = -1.18 (1.39), forced vital capacity (FVC) = -0.61 (1.46), forced expiratory flow between 25% and 75% of vital capacity​​​​​​ (FEF_25%-75% ) = -1.43 (1.10), FEV₁ /FVC = -1.04 (1.08)], Empey Index = 8.21 (1.59). The most common flow-volume curve pattern was the "knee" pattern (n = 39, 73.6%). Multivariable linear regression identified the presence of bronchomalacia was significantly associated with lower flows: FEV₁ [coefficient (95% CI) -0.78 (-1.54, -0.02)], FEF_25%-75% [-0.61 (-1.22, 0)], and PEF [-12.69 (-21.13, -4.25)], all p ≤ 0.05. Other bronchoscopic-defined tracheomalacia features examined (cross-sectional lumen reduction, malacic length) were not significantly associated with spirometry indices.

CONCLUSION

The "knee" pattern in spirometry flow-volume curve is common in children with tracheomalacia but other indices, including Empey index, cannot be used to characterize tracheomalacia. Spirometry indices were not significantly associated with bronchoscopic tracheomalacia features but children with tracheobronchomalacia have significantly lower flow than those with tracheomalacia alone.

Airway Malacia: Clinical Features and Surgical Related Issues, a Ten-Year Experience from a Tertiary Pediatric Hospital

Background: Few studies have been carried out with the aim of describing the clinical course and follow-up of patients with tracheomalacia. We aim to describe the symptoms at diagnosis and the post-treatment clinical course of patients affected by airway malacia. Methods: We retrospectively analyzed characteristics of pediatric patients with a diagnosis of airway malacia. Patients were classified into three groups: bronchomalacia (BM), tracheomalacia (TM) and tracheo-bronchomalacia (TBM). Demographic and clinical data, diagnostic work-up and surgical treatment were recorded. Results: 13/42 patients were affected by congenital syndromes (30.9%). Esophageal atresia with or without tracheal-esophageal fistula (EA/TEF) was detected in 7/42 patients (16.7%). Cardiovascular anomalies were found in 9/42 (21.4%) and idiopathic forms in 13/42 (30.9%). BM occurred in 7/42 (16.6%), TM in 23/42 (54.7%) and TBM in 12/42 (28.6%). At the diagnosis stage, a chronic cough was reported in 50% of cases with a higher prevalence in EA/TEF (p = 0.005). Surgery was performed in 16/42 (40%) of children. A chronic cough and acute respiratory failure were correlated to the need for surgery. During follow-up, there was no difference in persistence of symptoms between conservative vs surgical treatment (p = 0.47). Conclusion: the management of tracheomalacia remains a challenge for pediatricians. Clinical manifestations, such as a barking cough and acute respiratory failure may suggest the need for surgery. Follow-up is crucial, especially in those patients affected by comorbidities, so as to be able to manage effectively the possible persistence of symptoms, including those that may continue after surgical treatment.

Resorbable airway splint, stents, and 3D reconstruction and printing of the airway in tracheobronchomalacia

Tracheobronchomalacia (TBM) is the most common tracheobronchial obstruction. Most cases are mild to moderate; therefore, they do not need surgical treatment. Severe tracheomalacia, however, represents a diagnostic and therapeutic challenge since they are very heterogeneous. In the armamentarium of resources for the treatment of dynamic airway collapse, splints and stents are two underused strategies and yet, they may represent the best alternative in selected cases. Lately, computed tomography 3D reconstruction of the airway has been used for the design of virtual models that can be 3D-printed for the creation of novel devices to address training, simulation, and biotechnological implants for refractory and severe airway malformations. This manuscript examines the role of resorbable stents, splints, and the 3D reconstruction and printing of the pediatric airway in tracheobronchomalacia.

3D printing for tissue engineering in otolaryngology

Airway and other head and neck disorders affect hundreds of thousands of patients each year and most require surgical intervention. Among these, congenital deformity that affects newborns is particularly serious and can be life-threatening. In these cases, reconstructive surgery is resolutive but bears significant limitations, including the donor site morbidity and limited available tissue. In this context, tissue engineering represents a promising alternative approach for the surgical treatment of otolaryngologic disorders. In particular, 3D printing coupled with advanced imaging technologies offers the unique opportunity to reproduce the complex anatomy of native ear, nose, and throat, with its import in terms of functionality as well as aesthetics and the associated patient well-being. In this review, we provide a general overview of the main ear, nose and throat disorders and focus on the most recent scientific literature on 3D printing and bioprinting for their treatment.

ERS statement on tracheomalacia and bronchomalacia in children

Tracheomalacia and tracheobronchomalacia may be primary abnormalities of the large airways or associated with a wide variety of congenital and acquired conditions. The evidence on diagnosis, classification and management is scant. There is no universally accepted classification of severity. Clinical presentation includes early-onset stridor or fixed wheeze, recurrent infections, brassy cough and even near-death attacks, depending on the site and severity of the lesion. Diagnosis is usually made by flexible bronchoscopy in a free-breathing child but may also be shown by other dynamic imaging techniques such as low-contrast volume bronchography, computed tomography or magnetic resonance imaging. Lung function testing can provide supportive evidence but is not diagnostic. Management may be medical or surgical, depending on the nature and severity of the lesions, but the evidence base for any therapy is limited. While medical options that include bronchodilators, anti-muscarinic agents, mucolytics and antibiotics (as well as treatment of comorbidities and associated conditions) are used, there is currently little evidence for benefit. Chest physiotherapy is commonly prescribed, but the evidence base is poor. When symptoms are severe, surgical options include aortopexy or posterior tracheopexy, tracheal resection of short affected segments, internal stents and external airway splinting. If respiratory support is needed, continuous positive airway pressure is the most commonly used modality either via a face mask or tracheostomy. Parents of children with tracheobronchomalacia report diagnostic delays and anxieties about how to manage their child's condition, and want more information. There is a need for more research to establish an evidence base for malacia. This European Respiratory Society statement provides a review of the current literature to inform future study.

Aortopexy for Life-Threatening Airway Obstruction Following Division of Double Aortic Arch

Symptoms of airway compression secondary to double aortic arch are relieved by division of one of the two aortic arches. However, in some cases inherent tracheomalacia and other factors may result in persistence of symptoms. We report one such occurrence in our experience and describe the use of aortopexy as a curative procedure to tackle this problem.

Digital light procession three-dimensional printing acrylate/collagen composite airway stent for tracheomalacia

Recently, more and more researchers have focused on airway stent applied in tracheomalacia. The airway stents for clinical application were usually manufactured in accordance with a fixed pattern, which were difficult to perfect match with children, especially infants. Digital light procession of light curing acrylate resin implantation showed higher accuracy and printing speed over traditional three-dimensional printing techniques. In this article, a novel personalized airway stent was developed by digital light procession three-dimensional printing and was modified by collagen I extracted from the fish scales. The morphology of the collagen-modified airway stent was examined by scanning electron microscopy, and the chemical structures were examined by attenuated total internal reflectance Fourier transform infrared spectroscopy. The biocompatibility of this synthetic acrylate/collagen composite airway stent was characterized by water contact angle test and cell culture. The results confirmed that the composite airway stent was hydrophilic and non-cytotoxic toward a cultured human bronchial epithelial cell line with good cell viability and show excellent physicochemical and biological properties. In conclusion, this study presented the three-dimensional printing composite acrylate and collagen airway stent may have potential in customized treatment for tracheomalacia.

Tracheal and bronchial stenoses and other obstructive conditions

Although tracheal stenosis and bronchial stenosis are relatively rare in the pediatric population, they are both associated with significant morbidity and mortality. While most cases of congenital tracheal stenosis in children present as complete tracheal rings (CTRs), other congenital tracheal obstructions are also encountered in clinical practice. In addition, acquired obstructive tracheal conditions stemming from endotracheal trauma or previous surgical interventions may occur. Many affected children also have associated cardiovascular malformations, further complicating their management. Optimal management of children with tracheal or bronchial stenoses requires comprehensive diagnostic evaluation and optimization prior to surgery. Slide tracheoplasty has been the operative intervention of choice in the treatment of the majority of these children.

Pediatric tracheomalacia

Tracheomalacia (TM) is defined as an increased collapsibility of the trachea due to structural anomalies of the tracheal cartilage and/or posterior membrane. Tracheomalacia has a wide range of etiologies but is most commonly present in children born with esophageal atresia and tracheal esophageal fistula. Clinical symptoms can range from minor expiratory stridor with typical barking cough to severe respiratory distress episodes to acute life-threatening events (ALTE). Although the majority of children have mild-to-moderate symptoms and will not need surgical intervention, some will need life-changing surgical treatment. This article examines the published pediatric literature on TM, discusses the details of clinical presentation, evaluation, diagnosis, and a variety of treatments.

Thoracoscopic aortopexy for tracheomalacia

BACKGROUND

Tracheomalacia is a condition that may result in acute life-threatening events. Aortopexy has become a generally accepted mode of treatment, although the impact of a thoracotomy is considerable. With the advent of minimal invasive surgery the impact of such a procedure may be greatly reduced. This study evaluates the outcome of thoracoscopic aortopexy for tracheomalacia.

METHODS

Retrospective analysis of a database containing all patients with thoracoscopic aortopexy. Based on symptomatology, on indication 24 h pH study and/or rigid tracheo-bronchoscopy were carried out to confirm the diagnosis. A three-trocar technique was used on the left side together with intra-operative flexible tracheoscopy through the tube. Follow-up continued for the duration of the study.

RESULTS

Between January 2002 and December 2012, 16 patients presented with severe tracheomalacia. Fourteen of them had a history of esophageal atresia. Age at time of aortopexy varied from 2 weeks to 12 months. All procedures were performed thoracoscopically without intra-operative complications. In five children, there was a recurrence of symptoms within 2-4 weeks for which a re-thoracoscopic aortopexy was carried out successfully. With a follow-up of 6 months to 10 years all patients are thriving and are without incidents.

CONCLUSION

This is the largest single-center series of thoracoscopic aortopexy for tracheomalacia so far. All procedures were completed successfully without complications. Although recurrences occur, as in open surgery, the ultimate results are satisfactory. In an era of minimal invasive surgery the thoracoscopic approach is feasible and safe, even in redo-procedures.

Aortopexy with preoperative computed tomography and intraoperative bronchoscopy for patients with central airway obstruction after surgery for congenital heart disease: postoperative computed tomography results and clinical outcomes

Bronchoscopy-guided aortopexy is a surgical management option for patients with central airway obstruction after congenital heart surgery. This study aimed to evaluate the usefulness of bronchoscopy-guided aortopexy based on midterm follow-up evaluation with computed tomography (CT) and clinical outcome. From January 2004 to August 2011, bronchoscopy-guided aortopexy was performed for 16 patients (median age 0.5 years, M:F = 10:6) who had central airway obstruction caused by extrinsic compression (13 in the left main bronchus, 2 in the trachea, 1 in the diffuse trachea and bronchus) after congenital heart surgery. The surgical site for aortopexy was determined by the anatomic relationship between the aorta and the compressed bronchus according to preoperative CT and intraoperative bronchoscopy. The median follow-up period was 2.3 years. The ratios of the diameter and area of stenosis at the narrowed point were estimated using pre- and postoperative CT. Almost all the patients (15/16) showed relief of their preoperative symptoms. The median extubation time was 18 h. The stenosis diameter and area ratios significantly improved, as shown by with the immediate postoperative CT (7.7-48.5%, p = 0.003; 54.8-80.5%, p = 0.006). Airway stenosis of more than 75% (p = 0.013), immediate diameter ratio improvement of <50% (p = 0.015), preoperative severe respiratory insufficiency (p = 0.038), and male sex (p = 0.024) were associated with recurrent minor respiratory susceptibility. Bronchoscopy-guided aortopexy is a safe and reliable surgical management choice for central airway obstruction after congenital heart surgery. Furthermore, airway improvement after aortopexy was maintained during the midterm follow-up evaluation, according to CT measurements.

Treatment of severe porcine tracheomalacia with a 3-dimensionally printed, bioresorbable, external airway splint

IMPORTANCE

The study demonstrates use of a novel intervention for severe tracheobronchomalacia (TBM).

OBJECTIVE

To test a novel, 3-dimensionally (3D) printed, bioresorbable airway splint for efficacy in extending survival in a porcine model of severe, life-threatening TBM.

DESIGN AND PARTICIPANTS

A randomized, prospective animal trial was used to evaluate an external airway splint as treatment of severe, life-threatening TBM in a multi-institutional, multidisciplinary collaboration between a biomedical engineering department and an academic animal surgery center. Six 2-month-old Yorkshire pigs underwent tracheal cartilage division and inner tracheal lumen dissociation and were randomly assigned to splint treatment (n = 3) or control groups (n = 3). Two additional pigs had the splint placed over their normal trachea.

INTERVENTIONS

A 3D-printed, bioresorbable airway splint was assessed in a porcine animal model of life-threatening TBM. The open-cylindrical, bellow-shaped, porous polycaprolactone splint was placed externally and designed to suspend the underlying collapsed airway. Two additional animals were splinted without model creation.

MAIN OUTCOMES AND MEASURES

The observer-based Westley Clinical Croup Scale was used to assess the clinical condition of animals postoperatively. Animal survival time was noted.

RESULTS

Complete or nearly complete tracheal lumen collapse was observed in each animal, with resolution of symptoms in all of the experimental animals after splint placement. Using our severe TBM animal model, survival was significantly longer in the experimental group receiving the airway splint after model creation than in the control group (P = .0495).

CONCLUSIONS AND RELEVANCE

A multidisciplinary effort producing a computer-aided designed, computer-aided manufactured bioresorbable tracheobronchial splint was tested in a porcine model of severe TBM and was found to extend survival time. Mortality in the splinted group was ascribed to the TBM model based on the lack of respiratory distress in splinted pigs, long-term survival in animals implanted with the splint without TBM, and necropsy findings.

Outcomes of aortopexy for patients with congenital heart disease

Aortopexy is a surgical procedure in which the aortic arch is fixed at other structures, thus widening the interaortic space. This study aimed to evaluate the outcome of aortopexy by means of chest computed tomography for patients with congenital heart disease. The study retrospectively reviewed the medical records of 16 patients with congenital heart disease who had undergone aortopexy by compressed airway. The severity of compressed bronchus before aortopexy, immediately after aortopexy (≤ 1 month), and after the patient had grown up were compared. To estimate the efficacy of the aortopexy, the interaortic distance index was calculated. Of the 16 patients, aortopexy was performed at the ascending aorta in 7, at the descending aorta in 7, and at the transverse arch in 2. The diameter ratio between the narrowest bronchus and the trachea was improved after aortopexy, as was the diameter ratio before aortopexy versus immediately after aortopexy (n = 9; p = 0.018) and the diameter ratio before aortopexy versus after the patient had grown up (n = 11; p = 0.006). Also, the interaortic distance index was increased after aortopexy, as was the diameter before aortopexy versus immediately after aortopexy (n = 9; p = 0.039) and the diameter before aortopexy versus after the patient had grown up (n = 11; p = 0.014). The study had one case of mortality due to sepsis. As shown by the results, aortopexy in patients with a compressed airway between arches is a useful surgical option. Such a compressed airway between arches should be considered for patients with an unusual clinical course before and after open heart surgery.

Aortopexy for innominate artery tracheal compression in children

OBJECTIVES

(1) Evaluate the presentation, diagnostic workup, and outcomes of contemporary surgical intervention for airway obstruction from innominate artery tracheal compression in children. (2) Assess the significance of synchronous airway lesions in the treatment of innominate artery tracheal compression.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care children's hospital.

METHODS

This study is a retrospective medical record review of 26 consecutive children who underwent aortopexy for innominate artery tracheal compression at a tertiary care children's hospital. Presenting symptoms, diagnostic workup, presence of synchronous airway lesions, length of hospitalization, and treatment outcomes were examined.

RESULTS

Twenty-six patients (17 male, 65%) were included in the study. All were diagnosed with bronchoscopy and confirmed with radiographic imaging. Median age at diagnosis and surgery was 9.7 and 10.0 months, respectively. Presenting symptoms included noisy breathing (93%), cough (78%), dyspnea (44%), apnea (44%), cyanosis (19%), and recurrent respiratory infections (15%). Average degree of tracheal compression was 71% (SD, 12%). Fifteen of 26 (58%) patients had synchronous airway lesions, including mild laryngomalacia and subglottic stenosis. Median length of stay was 2 days. Median follow-up was 10 months. Subjective improvement occurred in all 21 patients for whom follow-up information was available.

CONCLUSION

Anterior tracheal vascular compression can cause a variety of airway symptoms. Mild synchronous airway lesions are common and do not prevent successful aortopexy. Aortopexy is a viable treatment option for symptomatic anterior tracheal vascular compression from the innominate artery.

Paediatric thoracoscopic surgery

Thoracoscopic surgery is now an integral part of paediatric practice. The evolution of instrumentation, optics and haemostatic devices have enabled even the most complex procedures to be carried out thoracoscopically. Although randomised studies are limited in children, thoracoscopic surgery appears to offer outcomes at least equivalent to that of open operations with less post-operative pain, less scarring and a more rapid recovery. Furthermore many of the long term musculo-skeletal deformities associated with a thoracotomy are avoided. There are however several surgical and anaesthetic challenges that make the widespread application of these techniques beyond that of specialised centres difficult.

Aortopexy for the treatment of tracheomalacia in children: review of the literature

Abstract

Severe tracheomalacia presents a significant challenge for Paediatricians, Intensivists, Respiratory Physicians, Otolaryngologists and Paediatric Surgeons. The treatment of tracheomacia remains controversial, but aortopexy is considered by most to be one of the best options. We conducted a review of the English literature relating to aortopexy.

Among 125 papers, 40 have been included in this review. Among 758 patients (62% males) affected with tracheomalacia, 581 underwent aortopexy. Associated co-morbidities were reported in 659 patients. The most frequent association was with oesophageal atresia (44%), vascular ring or large vessel anomalies (18%) and innominate artery compression (16%); in 9% tracheomalacia was idiopathic. The symptoms reported were various, but the most important indication for aortopexy was an acute life-threatening event (ALTE), observed in 43% of patients. The main preoperative investigation was bronchoscopy. Surgical approach was through a left anterior thoracotomy in 72% of patients, while median approach was chosen in 14% and in 1.3% a thoracoscopic aortopexy was performed. At follow-up (median 47 months) more than 80% of the patients improved significantly, but 8% showed no improvement, 4% had a worsening of their symptoms and 6% died. Complications were observed in 15% of patients, in 1% a redo aortopexy was deemed necessary.

In our review, we found a lack of general consensus about symptom description and evaluation, indications for surgery, though ALTE and bronchoscopy were considered by all an absolute indication to aortopexy and the gold standard for the diagnosis of tracheomalacia, respectively. Differences were reported also in surgical approaches and technical details, so that the same term “aortopexy” was used to describe different types of procedures. Whatever approach or technique was used, the efficacy of aortopexy was reported as high in the majority of cases (more than 80%). A subgroup of patients particularly delicate is represented by those with associated gastro-esophageal reflux, in whom a fundoplication should be performed. Other treatments of tracheomalacia, particularly tracheal stenting, were associated with a higher rate of failure, severe morbidity and mortality.

Non english abstract

La tracheomalacia severa rappresenta una sfida per Pediatri, Intensivisti, Pneumologi, Otorinolaringoiatri, Chirurghi Pediatri. Il trattamento della tracheomalacia è tuttora controverso. L’aortopessi è considerata da molti la migliore opzione terapeutica. Abbiamo condotto una revisione della letteratura di lingua inglese su tale argomento.

Di 125 lavori, 40 sono stati inclusi nella revisione. Tra 758 pazienti (62% maschi) affetti da tracheomalacia, 581 sono stati sottoposti ad aortopessi tra il 1968 e il 2008. In 659 pazienti alcune comorbidità erano presenti. L’associazione più frequente era con l’atresia esofagea (44%), l’anello vascolare o un’anomalia dei grossi vasi (18%), la compressione da parte dell’arteria innominata (16%); nel 9% la tracheomalacia era idiopatica. I sintomi riportati sono stati variabili, ma l’indicazione più importante all’aortopessi sono stati eventi di ALTE, osservati nel 43% dei pazienti. Lo studio diagnostico preoperatorio principale è stato la broncoscopia. L’approccio chirurgico è avvenuto attraverso una toracotomia anteriore sinistra nel 72% dei pazienti, mentre un approccio mediano è stato scelto nel 14% e nell’1.3% dei casi è stato eseguito un approccio toracoscopico. Al follow-up (mediana di 47 mesi) la maggioranza dei pazienti sono migliorati significativamente, ma l’8% di essi non è migliorato, il 4% è peggiorato e il 6% è morto. Complicazioni sono state riportate nel 15% dei pazienti, nell’1% un nuovo intervento di aortopessi è stato necessario.

In questa revisione abbiamo trovato che non c’è un consenso generale sulla valutazione e sulla descrizione dei sintomi, sulle indicazioni chirurgiche ed esami preoperatori, anche se le ALTE e la broncoscopia venivano considerate rispettivamente un’indicazione assoluta all’aortopessi e il “gold standard” diagnostico per la tracheomalacia. Venivano riportate differenze negli approcci chirurgici e nei dettagli tecnici, e lo stesso termine di aortopessi veniva usato per indicare diverse procedure chirurgiche. In ogni caso, indipendentemente dall’approccio o tecnica utilizzati, l’efficacia dell’aortopessi veniva riportata come elevata nella maggioranza dei casi (più dell’80%). Un sottogruppo di pazienti particolarmente delicato è rappresentato da quelli con reflusso gastroesofageo associato, nei quali sarebbe indicata una fundoplicatio. Altri trattamenti della tracheomalacia, quali stent tracheale, sembrano gravati da una maggiore percentuale di insuccessi, morbidità severa e mortalità.

Aortopexy as treatment for tracheo-bronchomalacia in children: an 18-year single-center experience

OBJECTIVES

To define the factors influencing the outcome of aortopexy as management of tracheo-bronchomalacia.

DESIGN

A retrospective, single-center, observational, cohort study.

SETTINGS

Surgical services in a tertiary care hospital.

PATIENTS

One hundred five children who underwent an aortopexy for tracheo-bronchomalacia between 1990 and 2008.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Comorbidity (categorized into three groups), surgical approach, and location of malacia were reviewed and analyzed in relation to mortality, need for a second intervention, complications, time to extubation after surgery, intensive care unit stay, and clinical improvement. Median age at surgery was 24 wks (1 wk-541 wks). Two surgical approaches were used: median sternotomy (n = 46) and left anterior parasternal (n = 59). Long-term (>2 yrs) follow-up was available for 73 patients (median = 7.0 yrs [2-18 yrs]); 73% were asymptomatic, 18% had minor symptoms, and 9% needed either ventilation or tracheostomy. The overall mortality rate was 9%, of which one-third was airway-related. Multivariable analysis revealed that major comorbidities were a significant risk factor both for mortality and the need for further procedures (re-do surgery, tracheostomy, internal stents) in contrast to surgical approach and involvement of the bronchus. Intensive care unit stay and days of ventilation after surgery were also significantly higher in patients with major comorbidities.

CONCLUSIONS

Aortopexy proved to be an effective treatment for most cases of tracheo-bronchomalacia, but major comorbidity was associated with an adverse outcome. Our data suggest that aortopexy should be considered in most cases of severe tracheo-bronchomalacia.

Severe bronchomalacia treated by combination of Nuss procedure and aortopexy: an unusual therapy combination

Aortopexy is the treatment of choice for clinically significant tracheobronchomalacia from external vascular compression. When a marked chest depression is present, aortopexy may be less effective. We report 2 patients with pectus excavatum and vascular compression of the trachea who, despite their young age, benefited from combined Nuss bar insertion and aortopexy.

Tracheal compression by aberrant innominate artery: clinical presentations in infants and children, indications for surgical correction by aortopexy, and short- and long-term outcome

BACKGROUND

Aberrant innominate artery (AIA) may cause various degrees of tracheal compression (TC).

PURPOSE

The aim of this study is to define the clinical manifestations of AIA-induced TC and outcome after aortopexy in infants and older children.

METHODS

Children with significant AIA-induced TC were evaluated, and information after surgery or conservative management was obtained by telephonic interview after 1 to 4 years since discharge.

RESULTS

Overall, 15 infants (mean age, 8 months; group A) and 13 older children (mean age, 56 months; group B) were evaluated. Although median age at onset of symptoms was comparable in the 2 groups, mean delay to diagnosis was higher in group B (P < .0001). Analysis of the most prevalent symptoms showed that reflex apneas were more frequent in group A (P = .02), whereas chronic "intractable" cough was more frequent in group B (P < .001). Because of the type and severity of symptoms and the degree of TC, 16 patients underwent aortopexy. Follow-up evaluation showed, in all but 1 patient, a significant improvement in symptoms and quality of life, measured by a modified Visick score.

CONCLUSIONS

Aberrant innominate artery-TC leads to a variety of respiratory disorders, with a difference in prevalence between infants and older children. When choice of treatment is based on clinical presentation and degree of TC, a good clinical outcome may be obtained also in children in whom aortopexy is indicated, that is, those presenting initially with more severe symptoms.