Ann Thorac Surg 2002;73:1969-1971
© 2002 The Society of Thoracic Surgeons
Case report
Autograft aortic arch extension and sleeve resection for bronchial compression after interrupted aortic arch repair
Max B. Mitchell, MDa*,
David N. Campbell, MDa,
Warren H. Toews, MDb,
Talat Z. Khan, MDc
a Department of Surgery, University of Colorado Health Sciences Center, Denver, Colorado, USA
b Department of Pediatric Cardiology, Presbyterian Saint Luke’s Medical Center, Denver, Colorado, USA
c Department of Pediatric Pulmonology, Presbyterian Saint Luke’s Medical Center, Denver, Colorado, USA
Accepted for publication December 5, 2001.
* Address reprint requests to Dr Mitchell, 1056 East 19th Ave, B200, Denver, CO 80218 USA
e-mail: mitchell.max{at}tchden.org
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Abstract
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Successful correction of bronchial compression and severe bronchomalacia complicating repair of interrupted aortic arch was achieved using transverse aortic arch extension with a pulmonary artery autograft and left bronchial sleeve resection. This procedure increased space within the aortic arch and eliminated bronchial narrowing with excellent results.
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Introduction
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Vascular compression of the airway after repair of interrupted aortic arch (IAA) may result in serious respiratory complications [1]. Aortopexy has been used for various types of vascular bronchial compression syndromes including bronchial compression after IAA repair [2]. Others have described arch remodeling with success when used early after arch repair [3]. Tracheostomy with prolonged mechanical ventilation has also been advocated [4]. Recently we performed transverse aortic arch extension using a pulmonary artery autograft and bronchial sleeve resection in a child with severe left bronchial compression after repair of IAA.
A 2.9-kg baby with type A IAA and perimembranous ventricular septal defect underwent extended end-to-end arch repair through a left thoracotomy followed by median sternotomy and uneventful VSD closure. At 5 months the child returned with wheezing, tachypnea, and labored breathing. Chest roentgenogram suggested left bronchial narrowing. Pulsatile anterior left bronchial compression was identified by bronchoscopy. Magnetic resonance imaging suggested vascular compression by the pulmonary artery (Fig 1).
Preoperative angiography demonstrated mild transverse arch tapering with no gradient and anteroposterior narrowing of the window bounded by the aortic arch (Fig 2).
Reoperation through a median sternotomy was performed. Intraoperative bronchoscopy demonstrated no relief of bronchial obstruction when the ascending aorta was displaced anteriorly precluding aortopexy. Complete dissection of the pulmonary arteries was performed exposing the left bronchus. This revealed a 10 mm segment of severe left-sided bronchomalacia beginning just distal to the carina. The cartilaginous portion of the diseased bronchus was translucent and visibly floppy with mechanical ventilation. We reasoned that bronchial resection was required to avoid long-term airway compromise, and that the space within the aortic arch must be increased to avoid recurrent bronchial compression.
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Fig 1. Magnetic resonance image demonstrating left bronchial compression. Note the very large main pulmonary artery (MPA) and the relationship between the right pulmonary artery (RPA), the narrowed left bronchus (LB), and the descending thoracic aorta (DTA).
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Fig 2. Angiogram demonstrating reduced space within the aortic arch and the mildly tapered transverse arch at the site of prior repair.
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The right atrium and ascending aorta were cannulated, and cardiopulmonary bypass was initiated. During cooling the branch pulmonary arteries were mobilized to each hilum, the entire aortic arch and branch vessels were dissected, and snares were placed around the head vessels. A 1 cm ring of main pulmonary artery was excised between the bifurcation and pulmonary valve (Fig 3).
Pulmonary artery continuity was reestablished with continuous 7–0 monofilament suture drawing the pulmonary artery bifurcation anteriorly away from the airway. The diseased segment of the left bronchus was excised, and an end-to-end anastomosis was performed with interrupted absorbable 6–0 monofilament sutures. The diameter of the ring of main pulmonary artery was reduced to the size of the proximal descending aorta by an opening through the narrowest point, excising the ends of the opened segment, and reconstructing the ring with a continuous 7–0 monofilament suture over a 10 mm dilator (Fig 3 inset). The ascending aorta was clamped and antegrade cardioplegia was delivered. Using deep hypothermic circulatory arrest, the transverse arch was transected through the narrowest region. Small longitudinal incisions were made in the inner curves of the proximal and distal ends of the divided transverse arch, and the autograft was inserted using a running 7–0 monofilament suture proximally and distally. Cardiopulmonary bypass was reestablished, and a pedicled flap of pericardium was wrapped around the bronchial anastomosis. Cardiopulmonary bypass was weaned, and a widely patent bronchial anastomosis without compression was confirmed by bronchoscopy. The child was discharged home 7 days later requiring only supplemental oxygen. Bronchoscopy performed at 3 months demonstrated a patent anastomosis. At 9 months follow-up the child is thriving. Serial echocardiograms reveal a widely patent arch without dilation and no evidence of branch pulmonary artery stenosis.
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Fig 3. (A) The cause of the left bronchial compression is depicted. An autograft ring of main pulmonary artery was resected and tailored appropriately (inset). (B) The pulmonary artery bifurcation was drawn anteriorly by direct anastomosis; a bronchial sleeve resection was performed; and the transverse aortic arch was extended using the autograft.
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Comment
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Posterior displacement of the ascending aorta and anterior displacement of the descending thoracic aorta after repair of the IAA may lead to vascular compression of the airway. This complication is usually caused by inadequate proximal and distal mobilization of the aorta and its branches during arch repair. In most cases the descending aorta compresses the left bronchus posteriorly. Failure to wean from mechanical ventilation after IAA repair should prompt investigation to rule out bronchial compression. When identified before the onset of structural bronchial damage simple decompressive techniques including aortopexy or arch remodeling may prove successful [2, 3]. In our patient, decompression alone would not have prevented further respiratory compromise caused by the severity of bronchomalacia evident after complete dissection of the bronchus. Anterior compression by the pulmonary artery is atypical in this setting, and previously described arch remodeling techniques did not appear efficacious in this patient. The severity of bronchial damage was likely caused by the delayed presentation, which was probably caused by bronchial compression of the lower pressure pulmonary artery compared with more typical cases with aortic compression. Resection of a segment of the pulmonary artery moved the bifurcation anteriorly away from the bronchial anastomosis and provided an autograft with potential viability to augment the anterior to posterior extent of the transverse aortic arch increasing the space available for the airway. We are not aware of any prior reports in which a pulmonary artery autograft has been used to extend the aortic arch. Conceivably, this maneuver could also be useful in correcting severe recurrent arch obstruction. Potential complications including future arch calcification, stenosis, or dilatation warrant careful long-term follow-up.[5]
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References
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Schreiber C., Eicken A., Vogt M., et al. Repair of interrupted aortic arch: results after more than 20 years. Ann Thorac Surg 2000;70:1896-1899.[Abstract/Free Full Text]
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Sakai T., Miki S., Ueda T., et al. Left main bronchus compression after aortic arch reconstruction for interruption of aortic arch. Eur J Cardiothorac Surg 1995;9:667-669.[Abstract]
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Pretre R., Turina M. Relief of bronchial compression caused by a congenital heart defect by remodeling of the aortic arch. J Thorac Cardiovasc Surg 2000;119:173-174.[Free Full Text]
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Davis D.A., Tucker J.A., Russo P. Management of airway obstruction in patients with congenital heart defects. Ann Otol Rhinol Laryngol 1993;102:163-166.[Medline]
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Elkins R.C., Knott-Craig C.J., Ward K.E., et al. Pulmonary autograft in children: realized growth potential. Ann Thorac Surg 1994;57:1387-1394.[Abstract]
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Abstract
Introduction
