QUAD #17 - Innominate Artery Compression and Management Through The Neck - Dr. Doug von Allmen

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, I'm Brittany Levy from Stay Current. And last year in October 2022, Cincinnati Children's hosted the Quad conference, which included the International Organization for Esophageal atresia, the Aerodigestive Society conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric dysphagia course. And today, we're going to review the innominate artery compression and how to manage this pathology through the neck with Doctor Doug Van Alman. So as a review about innominate artery compression, it was initially described in the 1940s by Gross et al. and thought to occur in about 30% of children under 2 years old. Certainly this is something that we can see pretty commonly on some of our routine bronchoscopies, at least partial in nominate artery compression. But certainly many of these patients are asymptomatic and we don't need to do anything. Now that changes when there's associated tracheomalacia or obstructive symptoms, then intervention should be considered. And of course, today we're talking about a cervical approach. So there's a couple of groups out of the UK that have described a cervical approach to the to the indominant artery, morbido et al. I talked about. Using a partial sternotomy, Yardley's group did about 22 patients through a lower transverse cervical incision, had improvement in the tracheal lumen of anywhere from 35 to 80%, and really saw an improvement in symptoms in 72% of their patients. Unfortunately, there was still a group of patients who did not experience the same benefit. The group that they really still struggle. With were these syndromic patients. So patient selection for this approach is key. Dr. Van Alman used this trans-cervical approach on a six month old transferred to Cincinnati Children's Hospital for evaluation. This is a long gap EA patient, um, who underwent a prior attempt, um, for repair, had some proximal pouch perforation, some issues with the TEF ligation. Uh, and they came to us with an esophagostomy on the right side, a right vocal cord paralysis, and they were requiring a CPAP of 8. They then proceed with bronchoscopy. You can see that approximately things are pretty open, but as we get down, you can see the the pulsations and the nominate artery compression. Interestingly, also that had this little E version of where the TEF had been ligated with a little bit of granulation tissue there. And then things. Open up after you get back through that, past that compression. To complete the workup, next, the team obtained a CT angiogram and identified the innominate artery high and was able to go back to the family with treatment options. And after discussion with our pediatric surgeon. Colleagues in the family, and we decided to pursue a nominate Py through the neck. So here, Dr. von Almen is performing that procedure and removing the thymus in order to skeletonize the sternum. Sometimes the sternum has a posterior hook at the top there and you can take part of that off of the kerosene. There's some ligamentous attachments down there that by dividing, we're able to create much more room to pull that artery forward. This is a delicate dissection while seltonizing the artery and the trachea. It's really important. To try not to dissect between the artery and the trachea. Um, we're pulling the artery forward in order to get resolution of some of that compression, but we also want to try to drag the anterior tracheal wall forward as well. So you see the team placing sutures through the sternum and eventually lifting the artery off the trachea. The nice thing about this approach is you have a really good view of the anterior tracheal wall and you can throw an anterior tracheopexy stitch if needed as well. Post-operatively, the bronchoscopy showed improvement of the tracheal lumen, which is something they've seen in many other cases as well. And eventually this patient was weaned off oxygen and discharged home on room air. Overall, the patients at Cincinnati Children's Hospital have done well with this approach. When we look at the results, 2 out of the 3 patients that had traches were decanulated. They had fairly medium length of stays, and we had some patients even that were in-house for 24 to 48 hours. Over time, the group has learned a lot about patient selection through reviewing their opportunities for improvement. Also, if you have reduced room in the thoracic outlet, you may have an inferior outcome. Darley's group identified the syndromic patients, um, but we went back and looked at the CT scans and looked at the distance between the inominate artery and the back of the sternum. We found that patients who had less than 1 centimeter of room there really had inferior results. So overall, the team tries to stick to specific patient selection guidelines. Ideally, we want the innominate artery to be high and easy to access through the neck. Additionally, these patients are discussed at a multidisciplinary conference to ensure They are always looking at the best approach for each patient and their pathology. In summary, a nominate artery compression should be evaluated for intervention in symptomatic patients with obstructive symptoms. This pathology has classically been approached in different ways. Dr. von Almen reviewed a trans cervical approach with good outcomes in the appropriate patient population. Thank you for watching this video. 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