Invited Commentary

Abstract

Dr McKenzie and associates from Texas Children’s Hospital are to be congratulated for presenting to us a novel operation for the relief of distal tracheal and bronchial compression [1McKenzie E.D. Roeser M.E. Thompson J.L. et al.Descending thoracic translocation for relief of distal tracheal and proximal bronchial compression.Ann Thorac Surg. 2016; 102: 859-863Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. It is rare in the current era to introduce an entirely new procedure! All of the children in this series had a descending thoracic aorta that crossed the midline, causing severe posterior compression of the distal trachea and bronchi. The operation was performed through a median sternotomy with the use of cardiopulmonary bypass and deep hypothermia. This procedure is, in many ways, a mirror image of the aortic uncrossing operation performed when the transverse aortic arch crosses from right to left above the carina [2Russell H.M. Rastatter J.C. Backer C.L. Aortic uncrossing procedure for circumflex aorta.Oper Tech Thorac Cardiovasc Surg. 2013; 18: 15-31Abstract Full Text Full Text PDF Scopus (25) Google Scholar]. The descending thoracic aorta was transected and brought up through the transverse sinus inferior to the carina and pulmonary artery. The aorta was then anastomosed to the posterior aspect of the ascending aorta. All children in the series had relief of their symptoms and no significant postoperative adverse events. One point that cannot be overemphasized—and I agree with the authors—is this: “an operation of this magnitude is justified only in severely symptomatic patients.” All of the patients in their series had required hospitalization for their symptoms. A substantial risk is associated with this operation when we consider all of the vital structures in the area (spinal cord, recurrent laryngeal nerve, vagus nerve, phrenic nerve). The authors are known to be superb technical surgeons, and their careful strategy of deep hypothermia and an expeditious operation still had an ischemia time to the distal thoracic aorta of 44 minutes. Careful attention to this cross-clamp time and spinal protection strategies are crucially important for this operation, as the authors have noted. One behind-the-scenes factor underlying this success is preoperative imaging with computed tomography or magnetic resonance imaging. High-quality advanced imaging with three-dimensional reconstruction is one of the keys to the success of this operation. For all children with vascular rings, the use of this advanced imaging to brainstorm strategies for innovative solutions is a new paradigm. I am confident that many children around the country may benefit from this operation. The use of preoperative three-dimensional advanced imaging will facilitate their identification. The use of this novel innovative surgical procedure will certainly improve the lives of these rare vascular ring patients. Descending Aortic Translocation for Relief of Distal Tracheal and Proximal Bronchial CompressionThe Annals of Thoracic SurgeryVol. 102Issue 3PreviewA descending thoracic aorta that traverses the midline is an uncommon cause of airway compression affecting the distal trachea and proximal main bronchi. Posterior aortopexy has had inconsistent results. Full-Text PDF