Left Pulmonary Artery Reimplantation Research Articles

Sliding tracheoplasty of complete tracheal cartilage rings in children

IntroductionComplete tracheal rings are a rare malformation that occurs in 1 out of 100,000 live births. It is rare, isolated tracheal or tracheobronchial anomaly developed due to abnormal cartilage growth with formation of complete ring and often resulting in airway stenosis. Slide tracheoplasty, as it was originally described by Tsang et al. and popularized by Grillo et al., overlaps stenotic segments of trachea, shortening trachea itself, thus, doubling the circumference and diameter of the stenotic area. Materials and methodsWe have performed slide tracheoplasty in 12 children during the period of 2019–2021 in thoracic surgery department of our center. Median age was 15 ± 21,1 months (2 months-6 years),median weight – 8,04 ± 4,75 kg (3–20,7 kg),tracheal lumen varied from 2.5 to 3.0 mm, stenosis length – from 40 to 70% of the trachea length. ResultsSlide tracheoplasty was performed using central veno-arterial extracorporeal membrane oxygenation in 7 cases and using cardiopulmonary bypass in 5 cases. Concomitant heart disease was revealed in 5 children (pulmonary artery sling in 3 cases, ventricular septal defects – 1, aberrant subclavian artery −1). 5 children underwent one-stage correction of VSD: plastic VSD –1; left pulmonary artery reimplantation – 3; subclavian artery reimplantation – 1. All patients were on mechanical ventilation for 4,3 ± 2,78 days at postoperative period. Patients were discharged 16,3 ± 5,14 days after surgery. Satisfactory result of treatment in the form of respiratory failure relief was achieved in 10 patients. It was possible to increase the trachea lumen from 1.5 to 2 times in all cases. There were 2 (16,6%) fatal cases due to sepsis and multi-organ failure development. ConclusionsChildren with complete tracheal rings are very complicated patients with various comorbidities. Despite the advances in medicine, sometimes it is impossible to save lives of these children. The use of extracorporeal circulation (ECMO and bypass) allows us to safely perform reconstructive surgery on the trachea and save the child from respiratory failure manifestations. If needed, simultaneous correction of heart and tracheal defects is possible. Slide tracheoplasty allows to increase trachea lumen at least in 1.5–2 times. Mechanical ventilation is an unfavorable predictive factor for the outcomes of congenital tracheal stenosis management. Level of evidenceIII.

Relationship between a Tracheal and Left Pulmonary Artery Stenosis Index and the Prognosis of Pulmonary Artery Sling with Tracheal Stenosis.

Pulmonary artery sling is a rare congenital pulmonary vascular malformation, often associated with tracheal or bronchial stenosis. Surgical treatment of pulmonary artery sling with tracheal stenosis (T) has a high risk of death and a relatively poor prognosis. This study explored the relationship between the T and left pulmonary artery stenosis (P) ratio and the effects of surgery for pulmonary artery sling with tracheal stenosis. Patients undergoing surgery for pulmonary artery sling in our center from January 2010 to December 2018 were retrospectively analyzed. Routine cardiac-enhanced computed tomography (CT) was performed preoperatively, and the P and T diameters were measured on the CT image. The T/P ratio was then calculated and analyzed. Thirty cases of pulmonary artery sling combined with tracheal stenosis were operated under cardiopulmonary bypass. The mean age at operation was 13.8 ± 13.6months (1.2-57.1months, Q1-Q3: 5-17months), and the mean body weight was 8.8 ± 3.5kg (3.8-17.3kg, Q1-Q3: 5.8-11.5kg). Twenty-three patients survived, and seven died, with an overall survival rate of 76.7%. Twenty-four patients underwent left pulmonary artery re-implantation, six patients underwent simultaneous left pulmonary artery re-implantation and slide tracheoplasty, and patients with intracardiac malformations (ventricular septal defect (n = 6) and atrial septal defect (n = 4)) underwent concurrent repair of the intracardiac defect. All cases had different degrees of tracheal stenosis, and the most narrowed trachea occurred with compression by the left pulmonary artery sling. The T/P ratio in the tracheoplasty group was significantly higher than that in the non-tracheoplasty group. The mortality rate in the T/P ≤ 1.15 group was significantly lower than that in the T/P > 1.15 group. Pulmonary artery sling treatment has a high risk of death. Left pulmonary artery re-implantation is an effective and safe surgical method for treating pulmonary artery sling, and slide tracheoplasty is an effective surgical method to correct tracheal stenosis. Children with T > 78.4% should receive active intervention for the tracheal stenosis, and these children have a considerable postoperative survival rate. The T/P ratio can be used to compare the relative superiority of the two compressions. A T/P ratio > 1.15 can be used as a reference index for intervention in tracheal stenosis and is a risk factor for postoperative death.

Tracheal development after left pulmonary artery reimplantation: an individual study

Pulmonary artery sling (PA sling) often presents as a life-threatening condition requiring urgent surgical correction. We reported 32 cases of PA sling in children who were followed up postoperatively in the past 6 years. All patients with PA slings who were admitted to the hospital from January 2012 to December 2017 and underwent surgery were retrospectively analyzed. The mean age of the 32 patients at repair was 16.97 months (range, 15 days to 128 months). Six patients required ventilator assistance for respiratory failure. All children underwent left pulmonary artery (LPA) reimplantation (n = 32), and 3 patients needed reimplantation slide tracheoplasty (n = 3) due to ventilation weaning failure. Four patients died, 27 patients survived until discharge, and 18 patients were followed up. Pulmonary computed tomography imaging and echocardiography were performed in 18 patients who were followed up. After LPA reimplantation, the tracheal carina area was significantly enlarged compared to that preoperation (p = 0.0002). In this follow-up cohort study, 75% of the patients who underwent LPA reimplantation survived until discharge. The survivors had subsequently well-developed pulmonary arteries and tracheas.

Pulmonary artery sling

Abstract Introduction Pulmonary artery sling is a rare congenital vascular anomaly in which the left pulmonary artery originates from the right pulmonary artery, encircles the distal trachea and right main stem bronchus, and requiring early surgical interventions. Case presentation We report a 8-month old girl who presented with 3 consecutive episodes within 2 months of recurrent respiratory symptoms and signs masquerading pneumonia. CT thorax and echocardiography showed an anomalous origin of the left pulmonary artery from the right pulmonary artery passing behind the trachea. A left pulmonary artery reimplantation without tracheoplasty was performed. The child recovered slowly but uneventfully after surgery, and was discharged home in good health after 2-month-stay in the hospital. Conclusion Although rare, pulmonary artery sling should not be overlooked in the differential diagnosis of children with recurrent respiratory symptoms. Prognosis after surgical repair without tracheoplasty seems to be good, and follow-up needs to be done routinely to identify the long-term consequences.

Pulmonary artery sling: diagnosis and surgical treatment

The aim — to study the experience in surgical treatment of isolated and associated pulmonary artery sling including tracheal, cardiac and aortic arch anomalies, to analyze the treatment strategy, complications and their correction.Materials and methods. Esophagography, digital subtraction angiography, contrast chest CT, tracheobronchoscopy, echocardiography were used for diagnosis. Surgery was used in all cases despite patient’s age, severity and associated lesions.Results and discussion. Over the 35­year period (1982 — 2017), 93 children were diagnosed and operated with different types of vascular rings in one center. Most of patients were under 3 year of age (n = 75; 80.6 %). Total of 8 (8.6 %) patients having pulmonary artery sling were included to the study. One of them had double vascular ring which included pulmonary artery sling and double aortic arch. Patients’ age at operation ranged from 21 days to 24 months (mean 12.9 ± 2.3, median 12.5), and weight ranged from 3.7 kg to 12.5 kg (mean 9.6 ± 0.9 kg, median 9.3 kg). Four of them (group I) (50 %) had isolated pulmonary artery sling and other 4 had associated airway or cardiac malformations (group II). Associated anomalies were as following: complete rings tracheal stenosis (n = 4), ventricular septal defect (n = 1), double vascular ring and total anomalous venous drainage (n = 1). Isolated pulmonary artery sling was corrected through left thoracotomy without cardiopulmonary bypass. Vascular anastomosis was performed using «fish mouth» technique to prevent postoperative stenosis. Median sternotomy and bypass were used in case of associated tracheal stenosis and ventricular septal defect. Tracheal resection or slide tracheoplasty were used for tracheal stenosis. In patient with double vascular ring and anomalous venous drainage surgery was staged: Rashkind procedure; then division of double aortic arch and left pulmonary artery reimplantation. Survival rate in the group I was 100 %, whereas in the group II 3 patients died, including that with double vascular ring. Overall mortality was 37.5 %. Stenosis of vascular anastomosis was corrected by balloon dilation in one case.Conclusions. Isolated pulmonary artery sling could be corrected through left thoracotomy without cardiopulmonary bypass, whereas associated anomalies should be managed using sternotomy approach and bypass. «Fish mouth» vascular anastomosis is effective in prevention of its stenosis. Balloon dilation of stenotic anastomosis in late period allows restoring an adequate blood flow in the left lung. Associated tracheal stenosis and cardiac defects has significant influence to the increase of mortality in patients with pulmonary artery sling. In case of associated heart defects simultaneous repair of cardiac hemodynamics and decompression of respiratory tract is expedient.

Prognostic analysis of patients with pulmonary artery sling combined with tracheal stenosis without tracheal intervention

Objective To analyze the prognosis of patients with pulmonary artery sling (PAS) combined with tracheal stenosis(TS) without tracheal intervention, and to discuss the method for improving the effect of treatment. Methods The clinical data of 17 children with PAS/TS (moderate or severe) who received treatment at Beijing Bayi Children′s Hospital Affiliated to General Hospital of Bejing Military Command from October 2011 to July 2015 were retrospectively analyzed, and the relationship between the effect and prognosis of re-implantation of the left pulmonary artery (LPA) without tracheal intervention was analyzed. Results Seventeen patients received re-implantation of the left pulmonary artery without tracheal intervention.Extubation was successfully performed in 12 of the 17 patients and they healed.The remaining 5 patients received tracheal intervention after the first operation but they all died.Of those 5 patients, 3 received tracheal stent implantation (1 died from necrotizing enterocolitis, 2 died from infection and multiple organ failure), and 2 received traheoplasty (both of them died from infection and tracheal fistula). Respiratory symptoms were reduced or resolved in all survivors.Diameter/length (%) in survivors without tracheal intervention was significantly higher than those who received tracheal intervention [(10.14±1.58)% vs.(5.72±1.17)%, t=3.600, P<0.001]. Patients with PAS undergoing LPA re-implantation achieved a good outcome if the diameter/length(%) of the trachea was up to (10.14±1.58)%.Patients with PAS undergoing LPA re-implantation achieved a bad outcome if the diameter/length(%) of the trachea was below to (5.72±1.17)%. Conclusions Most of patients with PAS/TS undergoing LPA re-implantation without tracheal intervention have a good outcome.It is feasible for them to avoid tracheal intervention.Diameter/length (%) may be a reliable indicator for determining tracheal intervention in surgical management of PAS. Key words: Pulmonary artery sling; Tracheal stenosis; Tracheoplasty; Prognosis

Treatment of 21 pediatric patients with pulmonary artery sling combined with tracheal stenosis

Objective Total 21 pulmonary artery sling(PA sling) combined with tracheal stenosis children who received treatment in our hospital were reviewed.The feasibility of treatment strategy including left pulmonary artery(LPA) re-implantation without tracheoplasty was discussed in this study. Methods From April 2009 to November 2015, a total of 21 pediatric patients received surgical treatment due to PA sling with tracheal stenosis.Six patients received LPA re-implantation and trachea intervention simultaneously.The other 15 patients received LPA re-implantation alone to relieve the trachea compression without tracheoplasty.The postoperative strategy including early extubation and CPAP ventilation was employed in PICU. Results A total of 21 PA sling with tracheal stenosis children who underwent surgical treatment in our hospital were recruited.There were 9 females and 12 males.Ages of these children were from 1 months to 10 years old, and body weights were from 2.9 kg to 25.0 kg.Five patients needed mechanical ventilation for severe respiratory symptoms preoperatively.Six patients received LPA re-implantation and tracheal intervention simultaneously.Among them, 3 patients received slide tracheoplasty, and one was discharged after recovery.The remaining 3 patients received tracheal stent implantation, but finally died.The survival rate was 16.7% in these patients.Fifteen patients received LPA re-implantation alone, and slide tracheoplasty was performed in 2 patients for extubation failure who finally died of air leakage.The survival rate of 15 patients who received LPA re-implantation alone was 86.7%. Conclusion The strategy in LPA re-implantation alone to relieve the trachea compression without tracheoplasty and early extubation and CPAP ventilation postoperative may be an ideal treatment for the pediatric patients with PLA sling combined with tracheal stenosis. Key words: Pulmonary artery sling; Tracheal stenosis; Left pulmonary artery re-implantation,

Single Stage Repair of Tetralogy of Fallot Associated With Left Pulmonary Artery Sling and Tracheal Stenosis

We report a rare case of tetralogy of Fallot (TOF) with left pulmonary artery (LPA) sling with tracheal stenosis. The patient underwent successful surgery in one stage involving intracardiac repair of TOF, LPA reimplantation and resection of tracheal stenosis with end-to-end anastomosis.

Is Tracheoplasty Necessary for All Patients With Pulmonary Artery Sling and Tracheal Stenosis?

Pulmonary artery sling frequently accompanies various degrees of tracheal stenosis. The authors reviewed their surgical outcomes for pulmonary artery sling from two institutions. From 1997 to September 2011, 16 patients with pulmonary artery sling underwent surgical treatment. Their median age was 4.6months and their body weight 6.2kg at the time of the operation. Of the 16 patients, 12 showed preoperative respiratory symptoms such as recurrent airway infection or dyspnea, with three of these patients receiving ventilator therapy preoperatively. Most of the patients showed various degrees of tracheal luminal stenosis and stenotic length, except for three patients who did not show significant airway stenosis. Left pulmonary artery reimplantation was performed for all the patients, but an accompanying tracheoplasty was performed for only two patients (one patch augmentation and one sliding tracheoplasty). After surgery, early extubation and intensive lung care were performed. Two operative mortalities occurred: one due to cardiac tamponade associated with postoperative bleeding and one due to aggravation of preexisting multiorgan failure. Two late mortalities occurred: one due to airway obstruction by repetitive granulation tissue growing at the tracheoplasty site and one due to pneumonia. The 12 living patients, including 11 patients who did not undergo tracheal surgery, showed no clinically significant airway problems at their last follow-up visit. The surgical outcomes for pulmonary artery sling without tracheoplasty were acceptable. The authors think tracheoplasty may be avoided by intensive postoperative airway management for a significant portion of the patients with pulmonary artery sling and tracheal stenosis.

Surgical management of pulmonary artery sling: Trachea diameter and outcomes with or without tracheoplasty

Pulmonary artery sling is frequently associated with tracheal and/or bronchial stenosis. A number of patients receive only re-implantation or relocation of the left pulmonary artery (LPA) while other patients may require tracheoplasty for stenosis of the airway. This study used computer tomography (CT) scans for the evaluation of airways and to evaluate the trachea diameter and the clinical outcomes with or without tracheoplasty. A total of 15 patients with PA sling who received CT scans were included in this study. We reviewed the clinical outcomes and the severity of trachea stenosis, and evaluated various surgical strategies. Among the 15 patients, one received only conservative treatment, 14 (93%) patients received LPA re-implantation, and eight (53%) received tracheoplasty. For the eight patients that received LPA reimplantation and tracheoplasty, five received slide tracheoplasty and all survived, two patients had pericardial patch augmentation and both died, and one patient received a resection and end-to-end anastomosis and survived. The diameter of the trachea in survivors without tracheoplasty was significantly larger than those who died or received tracheoplasty (3.2 ± 0.3 mm vs. 2.2 ± 0.4 mm, P = 0.003). Establishing 3.0 mm as the threshold, the positive predictive value for tracheoplasty or mortality was 89% and the negative predictive value was 83%. In this study cohort, approximately 60% of the patients with PA sling received tracheoplasty. A diameter of the trachea <3 mm is associated with the use of tracheoplasty or poor outcomes. Slide tracheoplasty provided acceptable good results.

Pulmonary artery sling: Current results with cardiopulmonary bypass

We have used cardiopulmonary bypass with left pulmonary artery reimplantation for pulmonary artery sling repair since 1985. This review presents our current results with this technique, emphasizing the importance of diagnosis and treatment of frequently associated tracheal stenosis. Since 1985, 34 patients have undergone pulmonary artery sling repair using a median sternotomy and cardiopulmonary bypass. Age ranged from 9 days to 43 years (mean 2.1 ± 7.5 years, median 0.2 years). Twenty-seven patients (79%) had tracheal stenosis secondary to complete cartilage tracheal rings. All patients had preoperative airway imaging with rigid bronchoscopy, and since 2000 all patients have had computed tomography imaging of the chest with 3-dimensional reconstruction (n = 14). Tracheal repair has included pericardial patch tracheoplasty (n = 7), tracheal autograft (n = 10), tracheal resection (n = 4), and slide tracheoplasty (n = 5). All patients had an echocardiogram, and cardiac lesions repaired simultaneously included atrial septal defect (4), tetralogy of Fallot (2), and ventricular septal defect (1). One patient had a severely hypoplastic right lung, and 3 patients had an absent right lung. In these patients, the left pulmonary artery was translocated anterior to the trachea. In all other patients, the left pulmonary artery was reimplanted into the main pulmonary artery. There have been no early deaths or complications related to the use of cardiopulmonary bypass. Median hospital stay was 24 days. There have been 4 late deaths. Two late deaths were the result of complications of tracheal surgery (1 pericardial patch [6 months postoperatively] and 1 autograft [1.7 years postoperatively]). One child died of biliary atresia (0.2 years postoperatively), and 1 child died of pneumonia (5.8 years postoperatively). All recent tracheal stenosis repairs have been with slide tracheoplasty. All left pulmonary arteries are patent with a mean percent flow by perfusion scan of 41% ± 13%. Older patients (n = 2) have noted a significant improvement in exercise tolerance. Pulmonary artery sling is best repaired with median sternotomy, cardiopulmonary bypass, and left pulmonary artery reimplantation. This resulted in uniformly patent left pulmonary arteries in all patients. Preoperative computed tomography imaging, echocardiography, and bronchoscopy are essential for precise operative planning. The frequently associated tracheal stenosis is best repaired with slide tracheoplasty.

Left Pulmonary Artery Sling–Anatomy and Imaging

Distinctive imaging findings are present when the left pulmonary artery (LPA) arises from the right pulmonary artery and forms a sling around the airway passing between airway and esophagus to reach the left lung. It is important to recognize the 2 distinct types of pulmonary sling. The less complex type I is associated with tracheobronchomalacia and is often managed successfully by LPA reimplantation. The more common and more complex type II is strongly associated with long segment tracheal stenosis. Appropriate management needs to address the airway abnormality in addition to the aberrant LPA. Both types, especially type II, are associated with cardiovascular, pulmonary, and other abnormalities that also need to be considered in therapeutic decisions. The role of imaging is to identify, define, and display the relevant anatomic relationships to facilitate appropriate management. Recent surgical advances have increased the likelihood of success of surgical correction of long segment airway stenosis.

Management of Pulmonary Artery Sling Associated With Tracheal Stenosis

Pulmonary artery sling is often associated with congenital tracheal stenosis and intracardiac anomalies. This study examines the influence of concomitant anomalies and individual surgical procedures. Between 1984 and 2006, 31 patients underwent surgical repair of pulmonary artery sling (median, 6 months; range, 29 days to 9 years). Twenty-eight of them underwent left pulmonary artery reimplantation and tracheoplasty, whereas the remaining 3 received only left pulmonary reimplantation. The first 4 patients with long segment tracheal stenosis were treated with a costal cartilage graft and the next 19 with slide tracheoplasty. Five patients underwent tracheal resection with end-to-end anastomosis. Associated cardiac anomalies in 10 patients were repaired concomitantly with left pulmonary artery reimplantation and tracheoplasty. Two patients died early of low-output syndrome (n = 1) and ventricular arrhythmia (n = 1). Follow-up was complete in all patients (median, 4.6 years) with 3 late deaths arising from residual tracheal stenosis or pulmonary hypertension. Two survivors with a costal cartilage graft remain free of respiratory problems. Of 16 survivors who underwent slide tracheoplasty, 9 who did not have tracheostomy are fully active and 7 had tracheostomy to treat tracheomalacia and granulation. Among 5 survivors of tracheal resection, 4 are doing well without tracheostomy. Echocardiography showed that the left pulmonary artery was patent in all assessed patients, but 1 required balloon arterioplasty. Left pulmonary reimplatation with simultaneous repair of tracheal stenosis and intracardiac anomalies results in low operative mortality and satisfactory left pulmonary artery patency. However, the management of younger infants with tracheoplasty for long segment stenosis involving carina or complex cardiac anomalies remains challenging.

Neonatal Right Lung Emphysema Due to Pulmonary Artery Sling

Pulmonary artery sling is a rare variant of vascular ring where the left pulmonary artery arises from the right and loops behind the trachea or right bronchus causing airway compression. A 40-day-old infant had been mechanically ventilated since birth for severe hypercapnia and right lung emphysema. Left pulmonary artery reimplantation was successfully performed.

Regression of the Systemic Vasculature to the Lung after Removal of Pulmonary Artery Obstruction

Pulmonary artery occlusion stimulates angiogenesis in the systemic circulation of the ipsilateral lung and increases systemic- to-pulmonary blood flow. Whether this systemic neovascularization decreases after lung revascularization is unknown. To assess the influence of lung revascularization on anatomy and flow of bronchial vessels supplying a chronically ischemic lung in piglets. Piglets were studied before (control) and 5 wk after left pulmonary artery ligation and 5 wk after left pulmonary artery reimplantation into the pulmonary artery trunk. The systemic blood flow to the right and left lungs was measured using colored microspheres, and the bronchial vasculature was assessed using light-microscopic morphometry. Renal and total blood flow, systemic blood pressure, and pulmonary blood pressure were measured in each experimental condition. Systemic blood flow to the left lung increased from 0.4 +/- 0.1 to 11.5 +/- 3.8 ml/min/g (p < 0.05) after left pulmonary artery ligation and returned toward the control value (1.2 +/- 0.6 ml/min/g) after revascularization, whereas it remained unchanged in the right lung. The number of bronchial vessels increased twofold in the ligated lung (p = 0.01), and did not decrease after reperfusion; however, vessel diameters decreased markedly. Renal and total blood flows, as well as mean pulmonary and systemic arterial pressures, were similar in the three experimental conditions. Revascularization after a period of left pulmonary artery occlusion normalizes the systemic blood flow to the left lung and induces partial loss of collateral vessels.

Surgical Treatment of Pulmonary Artery Sling and Tracheal Stenosis

Pulmonary artery sling is a rare vascular ring and is commonly associated with tracheal stenosis. Symptomatic newborns and infants with these complex lesions have a high mortality rate without surgical intervention. The ideal operation remains controversial, with debate focusing on the need for left pulmonary artery for reimplantation and the technique of tracheal reconstruction. From 1983 to 2003, 14 patients with pulmonary artery sling (mean age, 7 months; range, 6 days to 27 months) underwent repair of pulmonary artery sling alone (6 patients), tracheoplasty alone (1 patient), and pulmonary artery sling repair with tracheoplasty (7 patients). Preoperatively, 7 patients were intubated, 2 had VATER (vertebral, anal, tracheal, esophageal, and radial anomalies) syndrome, and 2 patients had agenesis of the right lung. The left pulmonary artery was reimplanted at the ductal insertion site in 13 patients. One patient had left pulmonary artery translocation. Tracheoplasty employing extracorporeal circulation consisted of autologous pericardial patch (6 patients) or slide tracheoplasty (2 patients). Six patients with pulmonary artery sling and mild tracheal stenosis required only left pulmonary artery reimplantation. Concomitant procedures included closure of atrial septal defect (4 patients), ventricular septal defect (4 patients), and shunt for Fallot's tetralogy (2 patients). There were 2 hospital deaths (2 of 14;14%) from abdominal sepsis (1) and renal failure (1). Reoperations included diaphragm plication (2), tracheostomy (1), and bronchoscopy with laser resection of granulation tissue (5 patients: 2 slide, 3 pericardium). Follow-up was complete in all patients (mean, 42 months) with 1 late death from fungal sepsis. At follow-up, all left pulmonary artery anastomoses were patent by echocardiography, and no patient has required reoperation for trachea reconstruction. These data demonstrate that tracheal repair is not always necessary in the presence of pulmonary artery sling; that agenesis of the right lung is not a contraindication to successful complete repair; and that simultaneous correction of intracardiac defects can be safely performed in selected patients. This study suggests that in newborns and infants, pericardial patch and slide tracheoplasty are effective methods for trachea reconstruction.