Ann Thorac Surg 2010;89:289-291. doi:10.1016/j.athoracsur.2009.05.080
© 2010 The Society of Thoracic Surgeons
Case Reports
Interposition Pericardial Flap After Slide Tracheoplasty in Pulmonary Artery Sling Complex
Igor E. Konstantinov, MD, PhD*,
Yves d'Udekem, MD, PhD,
Pankaj Saxena, MCh, DNB
Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
Accepted for publication May 26, 2009.
* Address correspondence to Dr Konstantinov, Royal Children's Hospital, Flemington Rd, Parkville, VIC 6009, Australia (Email: igor.konstantinov{at}rch.org.au).
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Abstract
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Children undergoing an extensive tracheoplasty, particularly those with associated cardiovascular anomalies, may require long cardiopulmonary bypass, prolonged ventilatory support, subsequent tracheostomy, and multiple reinterventions on the trachea. Thus, these rare patients are at risk of mediastinitis. With tracheal erosion into the adjacent vessels and tracheal perforation during subsequent bronchoscopic interventions. Herein we describe a simple technique of interposition pericardial flap that provides an effective seal and isolation of the tracheoplasty site.
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Introduction
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Pulmonary artery (PA) sling complex is a spectrum of anomalies that commonly includes left PA sling, patent ductus arteriosus, hypoplastic right lung, and severe long-segment tracheal stenosis [1]. In addition, approximately 12% of these patients have direct origin of the right epi-arterial bronchus, also known as "bronchus sui" or "pig bronchus" from the trachea [2, 3]. During the last decade slide tracheoplasty appears to have become a method of choice in repairing severe long-segment tracheal stenosis [4, 5]. However, less than 250 children underwent slide tracheoplasty worldwide. The operative mortality in a larger series of these patients reported during the last decade ranged from 5% to 33% [4, 5]. The PA sling complex and other concomitant cardiovascular anomalies add to complexity and risk of slide tracheoplasty.
An 8-month-old baby boy with a history of frequent respiratory tract infections was admitted to the intensive care unit in severe respiratory distress that required intubation. A chest roentgenogram demonstrated bilateral patchy atelectases. A computed tomographic scan demonstrated PA sling complex and severe long-segment tracheal stenosis of the bridging bronchus between the blunt stump of the rudimentary pig bronchus and the carina, as well as right lung hypoplasia (Fig 1A). Both bridging bronchus and right main bronchus collapsed without positive pressure ventilation. After 1 month of treatment for a respiratory infection and failure to decrease ventilatory support, the patient was referred for surgery. This surgery was performed through a midline sternotomy with cardiopulmonary bypass on the beating heart. An intraoperative examination confirmed the diagnosis of PA sling complex (Fig 1B) with left ligamentum arteriosum, severe ostial stenosis of the right PA, and tracheobronchial compression and malacia. The left PA was divided and reimplanted to the main PA. The stenotic segment of the right PA was resected and was re-anastomosed to the main PA. Cardiopulmonary bypass time was 190 minutes. Although the compression was effectively relieved, severe tracheomalacia persisted. In 1 week, after failure to wean the patient off ventilatory support, a slide tracheoplasty was performed with an extension into the right main bronchus (Fig 2A). Care was taken to avoid damage to the recurrent nerves. Division of the left pulmonary ligament, incision of the posterior pericardial reflection inferiorly, and hilar release contributed significantly to mobilization of the trachea, and allowed a tension-free anastomosis. The tracheobronchial tree was separated from the vascular structures by a flap of the anterior pericardium that was passed through the transverse sinus underneath the aorta and pulmonary artery (Figs 2B and 2C). Cardiopulmonary bypass time was 134 minutes. No cardiac arrest was required. Postoperatively, the patient required bronchoscopic resection of the granulation tissues above the surgical anastomosis at the site of endotracheal tube placement and tracheostomy, which was removed 6 months after the surgery. The bronchoscopy at that time demonstrated widely open airways and a stable tracheobronchial tree without stenoses. The patient was doing well at 8 months after surgery.
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Fig 1. (A) Computed tomographic scan demonstrates long-segment tracheobronchial narrowing with rudimentary stump of the bronchus sui, and (B) the pulmonary artery sling complex. The left pulmonary artery sling in combination with left ligamentum arteriosus caused compression of the trachea.
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Fig 2. (A) Division of the ligamentum arteriosus and reimplantation of both branch pulmonary arteries into the main pulmonary artery. (B) A broad flap of the anterior pericardium was harvested and passed through the transverse sinus, and (C) partially wrapped in front of the trachea, separating the tracheobronchial tree from the brachiocephalic artery, left carotid artery, ascending aorta, and pulmonary arteries.
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Comment
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A recent study of 40 children (11 of them had left PA sling) demonstrated that preoperative mechanical ventilatory support and duration of cardiopulmonary bypass were risk factors for prolonged postoperative ventilatory support [5]. Repairing PA sling complex and other cardiovascular anomalies increases complexity of surgery and duration of cardiopulmonary bypass, thus putting these patients at an even higher risk of prolonged postoperative ventilatory support. Patients with PA sling complex and tracheomalacia who require prolonged ventilatory support often have excessive endotracheal granulation tissue that develops at the site of mechanical irritation by the endotracheal tube. The granulation tissue requires bronchoscopic resection and dilation, and in severe cases also a temporary stenting [4, 5]. Subsequent bronchoscopic intervention and stenting carry the risk of perforation or erosion into the adjacent vessels (ie, a rare, but life-threatening complication). A spontaneous erosion of the trachea into the adjacent blood vessels after tracheoplasty may rarely occur in the absence of bronchoscopic intervention [2, 5]. Slide tracheoplasty itself, as well as subsequent interventions on the trachea after slide tracheoplasty, carries a risk of mediastinitis. In fact, some surgeons routinely irrigate the chest for 48 hours with povidone-iodine antiseptic on the assumption that the open tracheal surgery creates a latent mediastinitis [5].
Covering the trachea with the interposition pericardial flap after a tracheoplasty (as described herein) is a simple procedure that might be helpful in high-risk patients to re-enforce tracheal anastomotic seal, prevent mediastinitis, and prevent tracheal erosion into the blood vessels, as well as making subsequent bronchoscopic interventions safer.
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References
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- Chen SJ, Lee WJ, Lin MT, Wang JK, Chang CI, Chiu IS, Wu MH. Left pulmonary artery sling complex: computed tomography and hypothesis of embryogenesis Ann Thorac Surg 2007;84:1645-1650.[Abstract/Free Full Text]
- Gikonyo BM, Jue KL, Edwards JA. Pulmonary vascular sling: report of seven cases and review of the literature Pediatr Cardiol 1989;10:81-89.[Medline]
- Loukanov T, Sebening C, Springer W, Hagl S. A case of pulmonary artery sling associated with long-segment funnel trachea and bronchus suis Ann Thorac Surg 2004;78:1839-1842.[Abstract/Free Full Text]
- Manning PB, Rutter MJ, Border WL. Slide tracheoplasty in infants and children: risk factors for prolonged postoperative ventilatory support Ann Thorac Surg 2008;85:1187-1191.[Abstract/Free Full Text]
- Elliott M, Hartley BE, Wallis C, Roebuck D. Slide tracheoplasty Curr Opin Otolaryngol Head Neck Surg 2008;16:75-82.[Medline]
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Abstract
Introduction
