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Reoperation to correct unsuccessful vascular ring and vascular decompression surgery

Published:November 11, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.08.089

      Abstract

      Objective

      Although most children do well after operations to relieve vascular compression of the esophagus and airway, many will have persistent/recurrent symptoms. We review our surgical experience using a customized approach to correct various etiologies of failure after vascular ring/decompression surgery.

      Methods

      Our institutional database identified children who underwent reoperation for persistent/recurrent symptoms after vascular ring or aberrant arterial decompression surgery between January 2014 and December 2019. Charts were reviewed for operative approaches and clinical data. Findings were analyzed by Fisher exact test for comparison between groups.

      Results

      Twenty-seven children required reoperative surgery. Detailed preoperative workup identified 5 etiologies of failure for a customized approach. Residual scarring was corrected by lysis and rotational esophagoplasty (n = 23/27); fibrotic bands re-creating a ring were divided (n = 11); ongoing vascular compression was addressed by descending aortopexy (n = 19), aberrant subclavian division (n = 7), aortic uncrossing procedure (n = 4), and Kommerell resection (n = 8); anterior aortopexy (n = 6) and anterior tracheopexy (n = 9) corrected cartilage malformation; and tracheobronchomalacia was addressed with posterior airway pexy (n = 26). At available short-term follow-up (median 1 year), 21 of 22 patients (95%) had symptom improvement, and on bronchoscopy, the average number of airway sections with severe tracheobronchomalacia decreased from 2.8 ± 1.7 to 0.5 ± 0.9 (P < .001).

      Conclusions

      Persistent/recurrent symptoms after release of vascular compression are frequently caused by 5 different etiologies. A multidisciplinary strategy for workup and a customized operative approach can effectively treat these cases and may suggest opportunity at the index surgery to prevent reoperation and achieve optimal outcomes.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CT (computed tomography), L1 (left mainstem bronchus), R1 (right mainstem bronchus), TBM (tracheobronchomalacia)
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      Linked Article

      • Commentary: Vascular ring repair: Not always one and done
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1
        • Preview
          One of the gratifying components of vascular ring surgery is that usually these children have one operation and then are essentially “cured”—one and done. Over time, we have come to realize that a certain percentage of these patients will develop recurrent symptoms and need a reoperation. This dramatically increases the complexity of the operation and requires another level of preoperative evaluation and surgical expertise.
        • Full-Text
        • PDF
      • Commentary: Do we need such aggressive treatment?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1
        • Preview
          Vascular ring and vascular compression syndrome arise from the abnormal development of the aortic arch and its vessels resulting in compression of the esophagus or tracheobronchial tree, or both.1 Unusual location of the chest organ of heart, great vessel, trachea, bronchus, and esophagus also causes similar symptoms. Associated tracheobronchial stenosis or malacia is common. The majority of cases having surgical intervention for vascular compression will have relief of symptoms. However, a small proportion of these patients can return or persistently have respiratory or swallowing symptoms.
        • Full-Text
        • PDF