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Berry CM, Padilla LA, Sorabella R, Dabal RJ, Shah S, Nkengbeza LN, Gray WH. Outcomes for Children With Vascular Ring Repair Using a Simple Surgical Approach. J Surg Res 2024; 301:392-397. [PMID: 39029262 DOI: 10.1016/j.jss.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/23/2024] [Accepted: 06/23/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Vascular Rings (VRs) are congenital malformations of the aortic arch that can compress the trachea and esophagus producing symptoms. Approximately, 5%-10% of patients experience persistent symptoms postrepair and 9% require reintervention. There are various approaches to repair-simple ligation and division of the ring or more complex procedures. Our objective was to describe outcomes for VR repair using a "simple" surgical approach. METHODS We identified patients who underwent VR repair from 2012 to 2022 at our institution. Clinical and surgical data, demographics, intraoperative, and postoperative outcomes were extracted from their electronic medical records. Outcomes were analyzed and regression analysis was used to identify risk factors for residual symptoms after repair. RESULTS Ninety three patients with VR repair were included. Prevalence of symptoms were reduced following surgery (80% preoperative versus 13% postoperative, P 0.03). Tracheomalacia also decreased from 16% to 7% postrepair. No deaths were reported in our cohort and 2% of our patients required reintervention. Multivariable regression analysis showed that preoperative tracheomalacia was associated with having persistent symptoms after VR repair (odds ratio 6.2, 95% CI 1.02-37.6). CONCLUSIONS Our institutional experience using a simple surgical approach showed a significant decrease in symptoms, a very low reintervention rate and no mortality. Preoperative tracheomalacia can be a risk factor for persistent symptoms postrepair. We believe a simple surgical approach for children with complete VR repair can be effective in relieving symptoms.
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Affiliation(s)
- C Mason Berry
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert Sorabella
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shefali Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leopold N Nkengbeza
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - W Hampton Gray
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
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Mukharesh L, Krone KA, Hamilton TE, Shieh HF, Smithers CJ, Winthrop ZA, Muise ED, Jennings RW, Mohammed S, Demehri FR, Zendejas B, Visner GA. Outcomes of surgical treatment of tracheobronchomalacia in children. Pediatr Pulmonol 2024; 59:1922-1931. [PMID: 38629381 DOI: 10.1002/ppul.27012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 02/25/2024] [Accepted: 04/04/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND Tracheobronchomalacia (TBM) is characterized by excessive dynamic airway collapse. Severe TBM can be associated with substantial morbidity. Children with secondary TBM associated with esophageal atresia/tracheoesophageal fistula (EA/TEF) and vascular-related airway compression (VRAC) demonstrate clinical improvement following airway pexy surgery. It is unclear if children with severe primary TBM, without secondary etiologies (EA/TEF, vascular ring, intrinsic pulmonary pathology, or complex cardiac disease) demonstrate clinical improvement following airway pexy surgery. MATERIALS AND METHODS The study cohort consisted of 73 children with severe primary TBM who underwent airway pexy surgery between 2013 and 2020 at Boston Children's Hospital. Pre- and postoperative symptoms as well as bronchoscopic findings were compared with Fisher exact test for categorical data and Student's t-test for continuous data. RESULTS Statistically significant improvements in clinical symptoms were observed, including cough, noisy breathing, prolonged respiratory infections, pneumonias, exercise intolerance, cyanotic spells, brief resolved unexplained events (BRUE), and noninvasive positive pressure ventilation (NIPPV) dependence. No significant differences were seen regarding oxygen dependence, ventilator dependence, or respiratory distress requiring NIPPV. Comparison of pre- and postoperative dynamic bronchoscopy findings revealed statistically significant improvement in the percent of airway collapse in all anatomic locations except at the level of the upper trachea (usually not malacic). Despite some initial improvements, 21 (29%) patients remained symptomatic and underwent additional airway pexies with improvement in symptoms. CONCLUSION Airway pexy surgery resulted in significant improvement in clinical symptoms and bronchoscopic findings for children with severe primary TBM; however, future prospective and long-term studies are needed to confirm this benefit.
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Affiliation(s)
- Lana Mukharesh
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katie A Krone
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas E Hamilton
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Charles J Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Zachary A Winthrop
- Department of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eleanor D Muise
- Division of Pulmonary Medicine, Hassenfeld Children's Hospital at NYU Langone Health, New York, New York, USA
| | - Russell W Jennings
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Somala Mohammed
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Farokh R Demehri
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benjamin Zendejas
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Sengupta A, Brigger M, Lamberti JJ, Murthy RA. Recurrent Pediatric Respiratory Distress From a Challenging Vascular Anomaly: The Uncrossing Operation for Circumflex Aorta. JACC Case Rep 2024; 29:102305. [PMID: 38774806 PMCID: PMC11103596 DOI: 10.1016/j.jaccas.2024.102305] [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: 11/02/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 05/24/2024]
Abstract
The authors report a case of circumflex aorta causing persistent respiratory distress in a 9-year-old boy who had previously undergone vascular ring division and multiple aortopexies. The uncrossing operation was performed, with symptomatic relief of both posterior and right-sided tracheal compression from the transverse aorta and right aortic arch, respectively.
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Affiliation(s)
- Aditya Sengupta
- Division of Pediatric Cardiac Surgery, Department of Cardiovascular Surgery, The Mount Sinai Hospital, New York, New York, USA
| | - Matthew Brigger
- Division of Otolaryngology, Rady Children’s Hospital, San Diego, California, USA
| | - John J. Lamberti
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA
| | - Raghav A. Murthy
- Division of Pediatric Cardiac Surgery, Department of Cardiovascular Surgery, The Mount Sinai Hospital, New York, New York, USA
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Bartoli CR, Rajakumar CJ, Elmore JR, Ziemer G. Contralateral Thoracotomy With Extracorporeal Circulation for Reoperative Resection of a Kommerell Diverticulum. World J Pediatr Congenit Heart Surg 2024; 15:242-245. [PMID: 38378189 DOI: 10.1177/21501351231224385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Reoperative vascular ring surgery is uncommon. Standard redo ipsilateral thoracotomy may present technical challenges and risks. We describe a patient with right aortic arch, aberrant left subclavian artery, and a Kommerell diverticulum in whom previous vascular ring division via left thoracotomy did not relieve dysphagia. Three years after the unsuccessful operation, left subclavian-carotid transposition via supraclavicular incision followed by resection of the Kommerell diverticulum via right thoracotomy with extracorporeal circulation relieved symptoms. Contralateral thoracotomy with extracorporeal circulation provides a safe, alternative approach to redo ipsilateral thoracotomy for resection of a symptomatic Kommerell diverticulum. We review the literature on the incidence, surgical indications, and operative approaches to manage symptoms from a Kommerell diverticulum.
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Affiliation(s)
- Carlo R Bartoli
- Division of Cardiothoracic Surgery, Geisinger Medical Center, Danville, PA, USA
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | - James R Elmore
- Division of Vascular Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Gerhard Ziemer
- Division of Cardiothoracic Surgery, Geisinger Medical Center, Danville, PA, USA
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Wadle M, Joffe D, Backer C, Ross F. Perioperative and Anesthetic Considerations in Vascular Rings and Slings. Semin Cardiothorac Vasc Anesth 2024:10892532241234404. [PMID: 38379198 DOI: 10.1177/10892532241234404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.
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Affiliation(s)
| | | | - Carl Backer
- Kentucky Children's Hospital Congenital Heart Clinic, Lexington, KY, USA
| | - Faith Ross
- Seattle Children's Hospital, Seattle, WA, USA
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Backer CL, Mongé MC, Wallen WJ, Eltayeb O. The aortic uncrossing procedure. J Thorac Cardiovasc Surg 2024; 167:413-419. [PMID: 37406764 DOI: 10.1016/j.jtcvs.2023.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/10/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic arch from right to left posterior to the trachea and superior to the carina in a patient with a right aortic arch. We evaluated our patients who received an aortic uncrossing procedure. METHODS We reviewed all patients who underwent aortic uncrossing from 2002 to 2022. All patients received preoperative computed tomography imaging and bronchoscopy. RESULTS Eleven patients ranging in age from 1.5 to 10 years (median 4 years) underwent aortic uncrossing. Two patients had prior left ligamentum division, and 3 patients had prior left aortic arch division. All had significant clinical symptoms. Eight patients had deep hypothermic circulatory arrest (mean 34 minutes), and 3 patients had antegrade cerebral perfusion (median, 28 minutes). Patch material was not used for aortic augmentation, and no patient underwent a posterior tracheopexy or rotational esophagoplasty. Postoperative length of stay ranged from 4 to 31 days (median, 5 days). One patient required a temporary tracheostomy for bilateral recurrent laryngeal nerve paresis, which recovered. One patient required an aortic extension graft to alleviate esophageal compression from an unusual ectatic esophageal course. All patients had relief of airway symptoms and dysphagia. CONCLUSIONS In properly selected patients with a right aortic arch and circumflex aorta, aortic uncrossing is a safe and effective therapy to treat airway and esophageal compression. The procedure can be conducted with deep hypothermic circulatory arrest or antegrade cerebral perfusion. Careful attention to the location of the esophagus and recurrent laryngeal nerves is required.
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Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, Ohio.
| | - Michael C Mongé
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert J. Lurie, Children's Hospital of Chicago, Chicago, Ill; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - William J Wallen
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, Ohio
| | - Osama Eltayeb
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert J. Lurie, Children's Hospital of Chicago, Chicago, Ill; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Imamura M. Commentary: Do we need such aggressive treatment? J Thorac Cardiovasc Surg 2021; 164:209-210. [PMID: 34563371 DOI: 10.1016/j.jtcvs.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Michiaki Imamura
- Congenital Heart Surgery, Texas Children's Hospital, Houston, Tex.
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Backer CL. Commentary: Vascular ring repair: Not always one and done. J Thorac Cardiovasc Surg 2021; 164:208-209. [PMID: 34548156 DOI: 10.1016/j.jtcvs.2021.08.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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