Vascular tracheobronchial compression syndromes - Experience in surgical treatment and literature review

Between January 1988 and December 1997 a total of 22 patients (age: 8 days- 46 years) were operated for vascular airway compression syndromes with resp iratory insufficiency. Vascular anomalies in tracheal compression were doub le aortic arch in 7 patients, (2 previously operated elsewhere), right aort ic arch + left ligamentum arteriosum in 1, and pulmonary artery sling in 3. Three of these patients had secondary long-segment tracheomalacia. Compres sion of trachea and a main bronchus existed in Z patients with right aortic arch + left ligamentum. Isolated main bronchus obstruction was present in 9 patients (abnormal insertion of ligamentum arteriosum in 1, status post ( s.p.) previous operation for PDA in 4, s, p. surgery for coarctation in 1, right aortic arch + left ligamentum arteriosum in 2, and right lung aplasia + left ligamentum in 1). 3 of these cases had secondary long-segment bronc homalacia. All patients had a complex respiratory anamnesis [long-term intu bation in 7, s.p. tracheostomy in 2 (over 3 months - 3 years), and progress ive respiratory insufficiency in 13]. In tracheal compression, surgical cor rection included transsection of the underlying ring or sling components (w ith additional anterior aortic arch translocation in 5 patients resection-r eimplantation of left pulmonary artery in 3, segmental tracheal resection i n 1, and external tracheal suspension in 2). In the 2 cases with compressio n of the trachea and a main bronchus, aortic "extension" by a prosthetic tu be was necessary. In isolated main bronchus obstruction, surgical decompres sion basically consisted of transsection of the ligamentum arteriosum or re section of its scarry remnant forming the "corner point" of a compression b etween aorta and pulmonary artery. In 3 patients with secondary long-segmen t malacia, additional external bronchus suspension was performed. Effective decompression and re-expansion of the airway segment concerned was achieve d, and was demonstrated by intraoperative endoscopy in all patients. There were 3 postoperative deaths (sepsis 2; massive, irreversible edema of the t racheal mucosa 1). Of the 19 surviving patients 16 could be extubated betwe en the 1st and 17th (mean = 7.5) postoperative day. In 1 case the preoperat ive long-term tracheostomy had to be left in place for inoperable additiona l laryngeal structure. 2 patients had to be reoperated (segmental cervical tracheal resection after 5 months for primary long-term intubation-related subglottic stenosis in 1, esophageal decompression for residual dysphagia a fter 57 months related to a traction phenomenon at the right descending aor ta in the other), both with gratifying results. In all other patients clini cal, Endoscopic, and radiographic examinations (follow-up = 2 months - 6 ye ars) demonstrate good results.