Concomitant management of airway and its adjacent vascular pathology in addition to repair of congenital cardiac defects

Neonates with Right Aortic Arch Requiring Arch Reconstruction: A Single-Institution Experience

BACKGROUND

Reconstruction of a right aortic arch (RAA) is rarely required in the newborn period and has rarely been reported.

METHODS

All patients who underwent a RAA repair in the neonatal period from a single institution were retrospectively reviewed. The primary outcome measures included survival, complications, and reintervention.

RESULTS

Between 1984 to 2020, 15 patients were identified. Nine patients (60%) presented with an interrupted aortic arch (IAA), five (33%) with a hypoplastic arch, and one (7%) with anomalous origin of the brachiocephalic vessels. All patients had associated complex congenital heart disease. Median age at surgery was six days (range, 2-29), median weight 3.11 kg (range, 2.5-4.18). Genetic syndromes were prevalent and 77% of IAA patients had DiGeorge syndrome. Surgical techniques included end-to-side (27%), end-to-end (27%) or side-to-side anastomosis (13%) and placement of an interposition graft (7%). 65% required patch augmentation. Median intensive care unit and total hospital length of stay were 20 days (range, 7 - 92) and 28 days (range, 10 - 240), respectively. At median follow-up of 3.97 years (range, 0.19-36), 13 of 15 (87%) patients were alive. Vocal cord paralysis was found in 27%, hemidiaphragm paralysis in 13% and significant airway compression in 27%. Overall, 27% patients required reintervention on the aortic arch; two surgical and two percutaneous balloon dilation.

CONCLUSIONS

RAA reconstruction in the newborn period is rare and associated with complex lesions with an acceptable reintervention rate.

Vascular compression of the airway in children

Congenital heart disease (CHD) is an important clinical problem. Although survival has improved over recent decades, certain children with CHD remain difficult to treat, usually because of severe co-morbidity or uncorrectable defects. Vascular compression of the airway is one such co-morbidity, occurring in approximately 1-2% of children with CHD. It may be caused by congenital anomalies of the configuration of the great vessels, enlargement of otherwise normal structures or as a result of surgery. The anatomical patterns seen in these children may be complex, and as surgical correction is usually required to relieve the compression, the pre-operative imaging assessment should be as complete as possible. Precise diagnosis and therapy are essential because chronic airway compression in childhood carries a significant morbidity and mortality. Airway stenting is currently reserved for rare occasions when surgical correction is not possible.

The presentation and management of vascular rings: an otolaryngology perspective

OBJECTIVE

To review the presentation and natural history of children with vascular rings and present management guidelines.

METHODS

Retrospective study of tertiary care pediatric medical center charts from 1991 to 2002.

RESULTS

There were 37 males and 27 females with a diagnosis of vascular rings. At presentation, 91% of patients had airway symptoms and 47% had esophageal symptoms. Airway symptoms included stridor (63%), recurrent respiratory infections (47%), respiratory distress (19%), and cough (17%). The most common esophageal symptom was dysphagia (27%). Pre-operative studies included: echocardiography (96%), chest X-ray (93%), barium swallow (75%), magnetic resonance imaging (MRI) (60%), and computerized tomography (CT) scan of the chest (59%). Surgical management included open (n=25) and thoracoscopic (n=39) approach. Complications included recurrent laryngeal nerve injury in five patients (8%).

CONCLUSION

Children with vascular rings present with respiratory and/or feeding difficulty. The evaluation should include chest X-ray, echocardiography, and barium swallow. Direct laryngoscopy and bronchoscopy are recommended to assess the degree of compression of the airway and/or esophagus, tracheomalacia, and vocal fold motion prior to intervention. Indication for surgical release is given when the diagnosis is made and can be assisted by advanced radiology studies. Surgical options include minimally invasive techniques involving either thoracoscopic or robotic-assisted repairs, as well as open procedures involving thoracotomy.

Prognostic factors in the surgical treatment of congenital tracheal stenosis: a multicenter analysis of the literature

BACKGROUND

Congenital tracheal stenosis (CTS) often requires urgent surgical intervention. We evaluated prognostic factors to determine the risks of surgical interventions by conducting a retrospective review of recent case series.

METHODS

Cases of CTS between 2002 and 2004 from our institution and recently published series that provided primary data on the demographics, complications, and outcomes of patients with CTS were analyzed. Univariate, model fit, and multivariate logistic regression analyses were performed using the SAS Statistical Program.

RESULTS

There were 68 patients who were treated (cartilage patch tracheoplasty, n = 31; slide tracheoplasty, n = 37), with 19 deaths (overall mortality = 28%). A total of 10 patients who underwent cartilage patch tracheoplasty died (32% mortality), whereas only 9 patients died following slide tracheoplasty (24% mortality). A total of 8 of 11 patients who were repaired at the age of 1 month or younger died (73% mortality), whereas only 11 of 57 patients who were repaired at an age older than 1 month died (19% mortality) (P = .04). A total of 10 of 19 patients with CTS who had comorbid intracardiac anomalies died following CTS repair (53% mortality), whereas only 9 of 49 patients with CTS who did not have intracardiac anomalies died (18% mortality) (P = .02).

CONCLUSIONS

This is the first report on the prognostic factors determining surgical outcomes for CTS. The highest mortality rate was observed in CTS patients younger than 1 month and in those with intracardiac anomalies. Congenital tracheal stenosis repairs in these patient subgroups should be considered with caution.