Andersons pediatric cardiology 1275
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withreportedlynormalexercisetolerance.148However,morecontemporary
singlecenterstudieshavedemonstratedpatencyofallleftpulmonaryartery
reimplantations,albeitwithvariableflowratesbasedonnuclearmedicine
studies.149Freedomfromairwayreinterventionhasbeenshowntobebetterwith
slidetracheoplastycomparedwithothersurgicaltechniques.150Specifically,
therewasahigherincidenceofpostoperativeinterventionforgranulationtissue
formationandforairwaystentimplantationinpatientsundergoingpatch
tracheoplastycomparedtoslidetracheoplasty.150
InnominateArteryCompressionSyndrome
Theindicationforsurgicalinterventiononinnominatearterycompression
syndromeincludessymptomaticpatientswithevidenceofcompressionofmore
than80%ofthetracheallumenbyfiberopticbronchoscopy(Fig.47.29).90When
surgeryisindicated,anaortopexycanbeperformedthrougharight
submammarythoracotomyortheinnominatearterycanbetransectedand
reimplantedmoreanteriorlyontheaorta.151
FIG.47.29 Computedtomogramreformattedintransverseaxialand
coronalplanesshowingthebrachiocephalicarteryarisingfromtheaortaon
theleftsideofmidlineandcoursingrightwardinfrontofthetrachea.The
tracheaismildlycompressed.Notethattheanteroposteriordimensionof
thethoraxisnarrowinthiscase.LCCA,Leftcommoncarotidartery;LSA,
leftsubclavianartery;RIA,rightinnominateartery.
VascularCompressionoftheAirway
WithoutVascularRingorSling
Asdiscussedearlierinthischapter,theshapeofthethoraciccageisanimportant
factorthatcontributestocompressionoftheairwayandesophagusinpatients
withananomalousaorticarchorpulmonaryarterialsling.Inaddition,abnormal
positionordilationoftheotherwisenormallyformedvesselsmaycause
compressionoftheairwayoresophagus.Anelongatedaorticarchmayalso
compresstheanteriorwallofthetracheasignificantly,compromisingtheluminal
patency.152Aclassicexampleistherightaorticarchincongenitallycorrected
transposition(Fig.47.30).Inthissettingtheaortaascendsontheleftandtakesa
longtransversecourseinfrontofthetracheatoconnecttothedescendingaorta
intherightposteriormediastinum.Oncethelungsarehyperinflated,theyextend
tothemidlinebehindthesternum,pushingthemediastinalstructuresandheart
backward,furthercompromisingthetrachealandbronchialpatency.A
posteriorlydisplacedascendingaortamaycausesignificantcompressionofthe
airways.71,153Theascendingaortamaydirectlycompresstherightsideofthe
trachea.Inaddition,theleftmainbronchusand,lesscommonly,therightmain
bronchusarecompressedbytherightpulmonaryartery,whichisalsodisplaced
backwardbytheposteriorlydisplacedascendingaorta.
FIG.47.30 Inthispatientwithcongenitallycorrectedtranspositionanda
