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
Graphical Abstract
Key Words
Abbreviations and Acronyms:
CT (computed tomography), L1 (left mainstem bronchus), R1 (right mainstem bronchus), TBM (tracheobronchomalacia)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: November 11, 2021
Accepted:
August 13,
2021
Received in revised form:
July 26,
2021
Received:
April 29,
2021
Footnotes
Institutional Review Board P00004344; approval August 11, 2020.
Identification
Copyright
© 2021 by The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: Vascular ring repair: Not always one and doneThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1
- PreviewOne 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.
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- Commentary: Do we need such aggressive treatment?The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 1
- PreviewVascular 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.
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