EComment. Nuss pectus excavatum repair: friend or foe?

Abstract

In their recent article, Yuksel and coworkers conducted a prospective study of the internal thoracic artery (ITA) blood flow after placement of Nuss bar for the treatment of pectus excavatum (PEx). Yuksel and coworkers clearly demonstrated that the blood flow of these arteries is affected in 44% and 38% of patients with complete unilateral and bilateral obstruction, respectively [1]. Since ITAs are widely used for coronary bypass grafting, a history of PEx Nuss repair could impede the potential use of the ITA for coronary revascularization in the long term. We congratulate the authors for this interesting description of an unexpected effect of the Nuss procedure. In fact, other types of ITA lesions have already been reported following this technique. Besides perioperative injuries requiring emergent thoracotomy (2 cases in the English literature), Nuss bar pressure on the undersurface of the anterior chest wall or bar dislocation may result in: 1. ITA pseudoaneurysm treated successfully with selective embolization with coils [2]; 2. ITA rupture into the pleural cavity and consecutive life-threatening haemothorax requiring emergent thoracotomy or angiographic embolization [3–5]. In contrast, during the Ravitch-type PEx repair, the careful subperichondrial resection of elongated cartilages protects the internal thoracic vessels from perioperative damage. Furthermore, no delayed ITA lesions have been described in the literature following this procedure. In the discussion, Yuksel and coworkers list minor and severe complications associated with the Nuss repair [1]. Some of them are impressive, rendering the safety of the method questionable, in addition with the above-mentioned ITA injuries. Finally, the relevant article by Yuksel and coworkers describing an unexpected adverse effect of the Nuss repair validates our previous option of correcting PEx deformities exclusively by means of a simplified Ravitch-type technique. Conflict of interest: none declared