Reoperation to correct unsuccessful vascular ring and vascular decompression surgery

Abstract

Objective: Although most children do well after operations to relieve vascular compression of the esophagus and airway, many will have persistent/recurrent symptoms. We review our surgical experience using a customized approach to correct various etiologies of failure after vascular ring/decompression surgery.

Methods: Our institutional database identified children who underwent reoperation for persistent/recurrent symptoms after vascular ring or aberrant arterial decompression surgery between January 2014 and December 2019. Charts were reviewed for operative approaches and clinical data. Findings were analyzed by Fisher exact test for comparison between groups.

Results: Twenty-seven children required reoperative surgery. Detailed preoperative workup identified 5 etiologies of failure for a customized approach. Residual scarring was corrected by lysis and rotational esophagoplasty (n = 23/27); fibrotic bands re-creating a ring were divided (n = 11); ongoing vascular compression was addressed by descending aortopexy (n = 19), aberrant subclavian division (n = 7), aortic uncrossing procedure (n = 4), and Kommerell resection (n = 8); anterior aortopexy (n = 6) and anterior tracheopexy (n = 9) corrected cartilage malformation; and tracheobronchomalacia was addressed with posterior airway pexy (n = 26). At available short-term follow-up (median 1 year), 21 of 22 patients (95%) had symptom improvement, and on bronchoscopy, the average number of airway sections with severe tracheobronchomalacia decreased from 2.8 ± 1.7 to 0.5 ± 0.9 (P < .001).

Conclusions: Persistent/recurrent symptoms after release of vascular compression are frequently caused by 5 different etiologies. A multidisciplinary strategy for workup and a customized operative approach can effectively treat these cases and may suggest opportunity at the index surgery to prevent reoperation and achieve optimal outcomes.

Keywords: reoperation; tracheobronchomalacia; vascular ring.