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Yoo B, Lee B, Park JD, Kwon SK, Kwak JG. Prevention of Tracheo-Innominate Artery Fistula Formation as a Complication of Tracheostomy: Two Case Reports. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111603. [PMID: 36360331 PMCID: PMC9688328 DOI: 10.3390/children9111603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/08/2022] [Accepted: 10/21/2022] [Indexed: 01/25/2023]
Abstract
Tracheo-innominate artery fistula (TIF) is a rare complication of tracheostomy and refers to the formation of a fistula between the trachea and innominate artery. Because TIF is fatal, prevention rather than treatment is very important. Here we report the cases of two high-risk patients who underwent tracheostomy, and in whose cases attempts were made to lower the risk of TIF. In the first patient who developed a chest deformity with Duchenne muscular dystrophy, a tracheostomy was performed with a high-level (cricothyroid level) approach compared with the standard tracheostomy. In the second patient, the thoracic cage was relatively small due to a giant omphalocele, and the risk of a fistula forming was decreased by wrapping the innominate artery with an opened polytetrafluoroethylene vascular graft after resolving crowding of the intrathoracic cavity by total thymectomy. There was no TIF occurrence at the outpatient follow-up in either case. We expect that our approaches may be effective intervention measures for preventing TIF.
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Affiliation(s)
- Byungsun Yoo
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Bongjin Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-2072-3568
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Seong Keun Kwon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul 03080, Korea
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Murakami D, Miyamaru S, Nishimoto K, Ise M, Samejima Y, Ozasa S, Nakamura K, Orita Y. Therapeutic outcomes of laryngeal closure and laryngostomy in children with recurrent pneumonia. Int J Pediatr Otorhinolaryngol 2022; 160:111225. [PMID: 35797922 DOI: 10.1016/j.ijporl.2022.111225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/15/2022] [Accepted: 06/25/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE Children with medical complexity frequently experience difficulty breathing and swallowing and occasionally develop aspiration pneumonia. Long-term intubation may cause fatal trachea-innominate artery fistula (TIF). In the present study, we retrospectively evaluated the efficacy of laryngeal closure and laryngostomy in children with medical complexity. MATERIALS AND METHODS Laryngeal closure and laryngostomy were performed in eight children with severe neuromuscular disorders who were incapable of oral ingestion and verbal communication. The laryngostoma was placed at a higher position compared to that in conventional tracheostomies for easier management of the airway and to prevent TIF. RESULTS Aspiration was successfully prevented postoperatively in all cases. Laryngocutaneous fistula formation was not observed. Two patients successfully achieved oral ingestion capability and tracheal cannulas were removed in two patients. Among the six patients who needed a mechanical ventilator before surgery, two patients were weaned from mechanical ventilation. Five patients were successfully discharged from the hospital. Although two patients died because of their primary condition, pneumonia exacerbation was not observed in any of the patients. CONCLUSION Compared to the conventional tracheostomy, our procedure improved airway management and function in children with medical complexity and reduced the risk of TIF.
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Affiliation(s)
- Daizo Murakami
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Life Sciences, Kumamoto University, Japan.
| | - Satoru Miyamaru
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Life Sciences, Kumamoto University, Japan
| | - Kohei Nishimoto
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Life Sciences, Kumamoto University, Japan
| | - Momoko Ise
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Life Sciences, Kumamoto University, Japan
| | | | - Shiro Ozasa
- Pediatrics, Kumamoto University Hospital, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Japan
| | - Yorihisa Orita
- Department of Otolaryngology-Head and Neck Surgery, Faculty of Life Sciences, Kumamoto University, Japan
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Kanazawa Y, Kurata Y, Nagai M, Inoue K, Nozaki F, Mori A, Ishihara M, Mori M, Kumada T, Shibata M, Kato T, Nakai M, Kano M. Advantage of a higher position of the tracheostoma with glottic closure for preventing complications related to tracheostomy tube: a retrospective cohort study. BMC Surg 2022; 22:50. [PMID: 35148723 PMCID: PMC8832853 DOI: 10.1186/s12893-022-01505-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Surgery to prevent aspiration has complications related to tracheostomy tube, such as the trachea-brachiocephalic artery fistula. Glottic closure procedure makes tracheostoma at a position higher than the first ring of the trachea and theoretically has a potential to prevent such complications owing to a longer distance between the tip of tracheostomy tube and the tracheal membrane adjacent to the brachiocephalic artery. Our aim is to evaluate the safety of glottic closure in neurologically impaired patients by comparing outcomes with laryngotracheal separation. Methods This study is a single-center retrospective study from 2004 to 2019, using data of 15 and 12 patients who underwent glottic closure (GC) and laryngotracheal separation (LTS). The primary outcome was the incidence of postoperative complications induced by tracheostomy tube placement and adjustment of the tracheostomy tube position to prevent these complications, such as by converting to a length-adjustable tube and/or placing gauze between the skin and tube flange. Additionally, we analyzed the anatomical relationship between the tracheostomy tube tip and brachiocephalic artery and measured the distance between them using postoperative CT images. Results No patients in either group had trachea-brachiocephalic artery fistula. Erosion or granuloma formation occurred in 1 patient (7%) and 4 patients (33%) in the GC and LTS groups, respectively. Adjustment of the tracheostomy tube was needed in 2 patients (13%) and 6 patients (50%) in the GC and LTS groups. CT revealed a higher proportion of patients with the tracheostomy tube tip superior to the brachiocephalic artery in GC than LTS group. The mean tracheostoma-brachiocephalic artery distance was 40.8 and 32.4 mm in the GC and LTS groups. Conclusions Glottic closure reduces the risk of postoperative complications related to a tracheostomy tube. This may be due to the higher position of the tracheostoma at the level of the cricoid cartilage, increasing the distance between the tracheostoma and brachiocephalic artery. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-022-01505-2.
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Affiliation(s)
- Yuji Kanazawa
- Department of Otolaryngology, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan.
| | - Yasuhisa Kurata
- Department of Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, 54 Shogoinkawaharamachi, Sakyoku, Kyoto, 606-8507, Japan
| | - Miki Nagai
- Department of Otolaryngology, Sakai City Medical Center, 1-1-1, Ebarajicho, Nishiku, Sakai, 593-8304, Japan
| | - Kenji Inoue
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Fumihito Nozaki
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Atsushi Mori
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Mariko Ishihara
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Mioko Mori
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Tomohiro Kumada
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan.,Kumada Kids Family Clinic, 454-4 Kanegamorimachi, Moriyama, 524-0045, Japan
| | - Minoru Shibata
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Takeo Kato
- Department of Pediatrics, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Masako Nakai
- Department of Otolaryngology, Shiga Medical Center for Children, 5-7-30 Moriyama, Moriyama, 524-0022, Japan
| | - Makoto Kano
- Department of Otorhinolaryngology, Head and Neck, Ohara General Hospital, 6-1 Uwamachi, Fukushima, 960-8611, Japan
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Shimizu T, Takamizawa S, Yoshizawa K, Hatata T, Ishii J. A strategy to prevent tracheo-innominate artery fistula in the course of laryngotracheal separation: 9-year experience in a children's hospital. J Pediatr Surg 2022; 57:219-223. [PMID: 34844740 DOI: 10.1016/j.jpedsurg.2021.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 10/23/2021] [Indexed: 11/27/2022]
Abstract
AIM OF THE STUDY Laryngotracheal separation (LTS) is known to be the definitive solution for intractable aspiration pneumonia in neurologically impaired children. Postoperatively, a tracheostomy cannula is usually required. However, there are fatal cannula related complications such as a tracheo-innominate artery fistula (TIAF). We present our methods of preventing TIAF. METHODS A retrospective review in a single center from 2011 to 2019 identified 57 cases treated with LTS. We divided them into three groups: no pre-existing tracheostomy (n = 26), pre-existing tracheostomy with preservation of the pre-existing fistula (n = 20), and pre-existing tracheostomy without preservation of the pre-existing fistula (n = 11). The first group underwent traditional modified Lindeman's procedure. The second received transection of the trachea above the tracheostomy site, while the third had transection of the trachea at the tracheostomy site and creation of a distal end tracheostomy. Proper length and the angle of the cannula were selected to prevent damaging the innominate artery by the tip of the cannula. If the innominate artery compressed the trachea anteriorly, prophylactic arterial transection was considered. RESULTS Three patients (5.3%) died from causes unrelated to the surgical treatment. Only one patient had a postoperative TIAF followed by LTS (1.8%). Other postoperative complications were: wound infection (8.8%), intratracheal granuloma (12.3%), intratracheal minor bleeding (10.5%), wound granuloma (43.9%), leakage (1.8%). No one required revision of LTS. CONCLUSION Success rates of LTS were high without major complications in all three groups and implies a safe operation and a definitive solution to intractable aspiration.
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Affiliation(s)
- Toru Shimizu
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan.
| | - Shigeru Takamizawa
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan
| | - Katsumi Yoshizawa
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan
| | - Tomoko Hatata
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan
| | - Junya Ishii
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8288, Japan
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Du LW. Common carotid artery distortion before percutaneous dilatational tracheostomy. World J Emerg Med 2022; 13:242-244. [DOI: 10.5847/wjem.j.1920-8642.2022.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
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Morimoto N, Maekawa T, Kubota M, Kitamura M, Takahashi N, Kubota M. Challenge for management without tracheostomy tube after laryngo-tracheal separation in children with neurological disorders. Laryngoscope Investig Otolaryngol 2021; 6:332-339. [PMID: 33869766 PMCID: PMC8035946 DOI: 10.1002/lio2.534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/26/2020] [Accepted: 01/20/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The present study analyzed surgical outcomes of laryngotracheal separation (LTS) in children with neurological disorders. The purpose of this study was to investigate respiratory impairment and severe complications after LTS in children, and identify the possibility of permanent tracheostomy without a tracheostomy tube as the safest respiratory management method. METHODS Twenty-eight patients (male:female = 16:12) with neurological disorders (6 months to 32 years) who underwent LTS between January 2012 and April 2018 were reviewed. Tracheal diameter, Cobb angle, and sternocervical spine distance (SCD) were measured to assess the potential risk and possibility of removing tracheostomy tube management. RESULTS Tracheostomy tube could be removed shortly after LTS in 57% (16/28). However, nine of these patients developed respiratory problems that required tracheostomy tube placement 2 years after LTS. New requirements for a tracheostomy tube as a stent were strongly correlated with SCD (P < .05, odds ratio > 1) as well as tracheal deformity. CONCLUSIONS Respiratory management in neurologically impaired children after LTS without a tracheostomy tube is challenging because thoracic deformity during physical growth affects tracheal disfiguration. Thoracic deformities and progression of scoliosis should be considered in respiratory management approaches in children with neurological disorders, and long-term follow-up by computed tomography is necessary. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Noriko Morimoto
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Takanobu Maekawa
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
| | - Masaya Kubota
- Department of NeurologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Masayuki Kitamura
- Department of RadiologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Nozomi Takahashi
- Department of OtolaryngologyNational Center for Child Health and DevelopmentTokyoJapan
| | - Mitsuru Kubota
- Department of General Pediatrics and Interdisciplinary medicineNational Center for Child Health and DevelopmentTokyoJapan
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Suzuki K, Fujishiro J, Ichijo C, Watanabe E, Tomonaga K, Sunouchi T, Watanabe Y. Prophylactic innominate artery transection to prevent tracheoinnominate artery fistula: a retrospective review of single institution experiences. Pediatr Surg Int 2021; 37:267-273. [PMID: 33388953 DOI: 10.1007/s00383-020-04792-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE This study aimed to investigate the optimal indication and availability of prophylactic innominate artery transection (PIAT). METHODS We retrospectively analyzed the medical records of the patients with neurological or neuromuscular disorders (NMDs) who underwent PIAT. Meanwhile, we originally defined the tracheal flatting ratio (TFR) and mediastinum-thoracic anteroposterior ratio (MTR) from preoperative chest computed tomography imaging and compared these parameters between non-PIAT and PIAT group. RESULTS There were 13 patients who underwent PIAT. The median age was 22 years. PIAT was planned before in one, simultaneously in five, and after tracheostomy or laryngotracheal separation in seven patients. Image evaluations of the brain to assess circle of Willis were performed in all patients. Appropriate skin incisions with sternotomy to expose the innominate artery were made in four patients. All patients are still alive except one late death without any association with PIAT. No neurological complications occurred in any patients. As significant differences (p < 0.01) between two groups were observed for TFR and MTR, objective validity of the indication of PIAT was found. CONCLUSIONS PIAT is safe and tolerable in case of innominate artery compression of the trachea with NMDs. TFR and MTR are useful objective indexes to judge the indication of PIAT.
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Affiliation(s)
- Kan Suzuki
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Jun Fujishiro
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Chizue Ichijo
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Eiichiro Watanabe
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kotaro Tomonaga
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tomohiro Sunouchi
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yasuo Watanabe
- Department of Pediatric Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Antunes LA, Talini C, Carvalho BCND, Guerra JP, Aristides EDS, Oliveira DED, Avilla SGA. Laryngotracheal separation in pediatric patients: 13-year experience in a reference service. EINSTEIN-SAO PAULO 2019; 17:eAO4467. [PMID: 31166409 PMCID: PMC6550435 DOI: 10.31744/einstein_journal/2019ao4467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 11/05/2018] [Indexed: 11/05/2022] Open
Abstract
Objective: To evaluate clinical stability of neurologically impaired children and adolescents with recurrent pneumonia submitted to laryngotracheal separation. Methods: Between October 2002 and June 2015, 92 neurologically impaired children from a reference service, with median age of 68.5 months were submitted to laryngotracheal separation. Data were evaluated and statistical analysis was made by Student's t test and Pearson's χ2 test (significance level adopted of 95%). Results: Fifty-three children were male (57.6%). Forty-six children required admission to intensive care, and 42.4% needed mechanical ventilation. We observed that 90.2% of patients were exclusively fed by gastrostomy and 72.4% of the gastrostomies were performed before the tracheal surgery. Thirteen (14.1%) children had postoperative complications as follows: fistulae (5.4%), bleeding (4.3%), granuloma (2.2%) and stenosis (3.2%). A total of 24 patients had pneumonia in the postoperative period (26.1%), but there was a significant drop in occurrence of this condition after surgery (100% versus 26.1%; p<0.001). Twenty-three patients (25%) died. Postoperative complications were similar when comparing patients who died and those that presented good outcome (16.7% versus 13.2%; p=0.73). Conclusion: When well-indicated, the laryngotracheal separation reduces the incidence of postoperative pulmonary infections, thus improving quality of life and reducing admissions to hospital. Laryngotracheal separation should be indicated as a primary procedure in patients with cerebral palsy and recurrent aspiration pneumonia.
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Ise K, Kano M, Yamashita M, Ishii S, Shimizu H, Nakayama K, Gotoh M. Surgical closure of the larynx for intractable aspiration pneumonia: cannula-free care and minimizing the risk of developing trachea-innominate artery fistula. Pediatr Surg Int 2015; 31:987-90. [PMID: 26276429 DOI: 10.1007/s00383-015-3780-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 11/29/2022]
Abstract
There is a risk of developing a fatal trachea-innominate artery fistula following laryngotracheal separation for the prevention of intractable aspiration pneumonia. We developed a novel technique of surgical closure of the larynx to avoid this complication and provide long-term cannula-free care.
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Affiliation(s)
- Kazuya Ise
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan.
| | - Makoto Kano
- Department of Otorhinolaryngology, Head and Neck, Ohara General Hospital, 6-11 Ohmachi, Fukushima-shi, Fukushima, 960-8611, Japan
| | - Michitoshi Yamashita
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Show Ishii
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Hirofumi Shimizu
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Kei Nakayama
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
| | - Mitsukazu Gotoh
- Pediatric Surgery, Fukushima Medical University, 1 Hikarigaoka, Fukushima-shi, Fukushima, 960-1295, Japan
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Innominate artery transection for patients with severe chest deformity: optimal indication and timing. Pediatr Surg Int 2012; 28:877-81. [PMID: 22948666 DOI: 10.1007/s00383-012-3138-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE The innominate artery sometimes compresses the trachea, leading to tracheomalacia and highly fatal tracheoinnominate fistula in patients with severe chest deformity. This study is focused on the indication of innominate artery transection for the definitive treatment of these complications. PATIENTS AND METHODS We retrospectively analyzed the medical records of eight patients who underwent transection of innominate artery. RESULTS All patients had developed severe chest deformity and their symptoms were life-threatening anoxic spell or endotracheal hemorrhage. Bronchoscopy showed tracheomalacia with or without pulsatile granulations on the anterior wall of the trachea underlying the innominate artery. In six cases who had previously undergone tracheostomy or laryngotracheal separation, the tracheal tube tip made granulations or tracheoinnominate fistulas. In addition to transection of innominate artery, the tracheoinnominate fistula was closed in two cases and the artery was transposed in one. All patients survived without neurologic complications and airway symptoms postoperatively. CONCLUSIONS For patients with severe chest deformity, innominate artery transection is indicated when they have tracheal compression by the artery and need to be intubated through the compressed part of trachea to secure the airway. This would be the best timing to schedule the prophylactic operation.
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