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Ann Thorac Surg 1999;68:994
© 1999 The Society of Thoracic Surgeons

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Commentary

^a Department of Cardiac Surgery, Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, USA

e-mail: jonas_r{at}al.tch.harvard.edu

Invited commentary

Pulmonary artery sling is a rare and very heterogeneous condition. In our experience it is almost always associated with complete tracheal rings, and often affects the entire length of the trachea. One of the common misperceptions about this condition it that tracheal stenosis occurs secondary to compression by the left pulmonary artery, as it runs its anomalous course between the distal trachea and the esophagus. However, this is almost certainly not the case since we and others have seen many variations of congenital tracheal stenosis associated with pulmonary artery sling. These can range from a profound degree of hypoplasia of the entire tracheobronchial tree, to a discrete stenosis quite separate from the sling. Interestingly, tracheomalacia is usually not a feature.

In view of the heterogeneity of pulmonary artery sling and associated congenital tracheal stenosis, we do not believe that a single surgical approach should be applied. As with all congenital anomalies, it is important to assess the specific characteristics of an individual child’s problem, and to subsequently design an appropriate operation for that child. In our experience, resection and end-to-end anastomosis has been an extremely reliable technique for dealing with discrete tracheal stenoses. The mobility of the neonatal and infant trachea allows one-third of the trachea to be resected quite comfortably. Slide tracheoplasty is a useful technique for longer segment stenosis, and may be combined with resection of the most severe area of tracheal obstruction. Without question the most important principle in both of these procedures is to avoid leaving residual stenosis. We have not seen anastomotic dehiscence in a large series of patients both with pulmonary artery sling and other congenital tracheal anomalies. In contrast, pericardial patch plasty has an important disadvantage, as it is initially quite malacic for several weeks. This has led most centers that undertake large volumes of congenital tracheal surgery to abandon this technique.

In the accompanying article, van Son and colleagues argue against tracheal resection in favor of pericardial patch plasty for tracheal stenosis associated with pulmonary artery sling. They also believe that two of their patients experienced anterior tracheal compression by the anteriorly translocated left pulmonary artery. In our experience applying this technique in over a dozen patients, anterior tracheal compression has not been a problem. As stated above, we believe that tracheomalacia is rarely associated with the pulmonary artery sling, and speculate that perhaps the complete tracheal rings, if anything, make the trachea more resistant to compression than may be seen with a normal trachea. On the other hand, we have certainly seen patients in whom the left pulmonary artery runs an unnecessarily redundant course if it is simply translocated. If this appears to be the case, then it is a simple matter to divide the left pulmonary artery at its origin and reimplant it in a more anatomically desirable location. However, we continue to argue against division and reimplantation in all patients since without question it is possible to translocate the left pulmonary artery and have satisfactory flow distribution. We are in full agreement with the authors, however, that if the degree of associated congenital tracheal stenosis is mild or moderate, then a tracheal procedure should not be undertaken and the left pulmonary artery should simply be divided and reimplanted. We continue to use a median sternotomy approach as well as cardiopulmonary bypass for both procedures.

In summary, we believe that resection with end-to-end anastomosis is the best technique for dealing with discrete short segment tracheal stenosis whether or not it is associated with a pulmonary artery sling, and argue against the technique of pericardial patch plasty in this setting.

Related Article

Pulmonary artery sling: reimplantation versus antetracheal translocation

Jacques A.M. van Son, Jörg Hambsch, Gary S. Haas, Peter Schneider, and Friedrich W. Mohr
Ann. Thorac. Surg. 1999 68: 989-994. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

				S. Hagl, C. Sebening, W. Springer, and T. Loukanov Modified Sliding Tracheal Plasty Using the Bridging Bronchus for Repair of Long-Segment Tracheal Stenosis Ann. Thorac. Surg., March 1, 2008; 85(3): 1118 - 1120. [Abstract] [Full Text] [PDF]

				T. Loukanov, C. Sebening, W. Springer, and S. Hagl A Case of Pulmonary Artery Sling Associated With Long-Segment Funnel Trachea and Bronchus Suis Ann. Thorac. Surg., November 1, 2004; 78(5): 1839 - 1842. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard A. Jonas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jonas, R. A. Search for Related Content PubMed Articles by Jonas, R. A. Related Collections Related Article