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J Thorac Cardiovasc Surg 1994;107:947-948
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Aortoinnominopexy versus innominate artery reimplantation for displaced innominate artery

Departments of Cardiothoracic Surgery and Pediatrics
Loyola University Medical Center
Maywood, IL 60153

To the Editor:

Displacement of the innominate artery can cause tracheal compression and produce such problems as reflex apnea, respiratory distress, and recurrent upper respiratory tract infections. Reported prevalences of displaced innominate artery vary widely. Institutional awareness and aggressiveness on the part of the otolaryngologist leads to increased recognition and higher prevalence figures. The main diagnostic tool is bronchoscopy, which shows the characteristic anterior pulsatile compression of the trachea.

Because the tracheal rings are soft and collapsible in infancy, symptoms usually appear early. The condition of the patient, however, gradually improves, and rarely do significant problems persist beyond infancy. Selecting patients for surgical correction can be difficult. Reflex apnea, however, can be life-threatening, and probably patients with such problems should be operated on provided results of neurologic, sleep, and reflex studies are normal.

Which surgical approach is most appropriate for displaced innominate artery is not settled. Hawkins, Bailey, and Clark ¹ reported that transection and reimplantation produced resolution of symptoms in 97% of patients. In their response to the criticisms of Backer, Hollinger, and Mavroudis, ² they claimed that they switched to reimplantation because of two failures among nine patients undergoing suspension, with only 50%of patients having immediate relief of symptoms. The reimplantation procedure, however, appears radical for a problem that is self-limiting, and there are always long-term concerns with vascular anastomosis in infancy.

Simple suspension of the innominate artery is challenging because of lack of sturdy enough tissue attached to the artery to hold sutures. Because of such problems, materials such as muscles and pericardium had been used to loop around the innominate artery. We have also reported our extensive experience ^3-6 with operations for displaced innominate artery in more than 70 patients, and in 1977 we even submitted our early series to The American Association for Thoracic Surgery. Our technique has evolved through the years from simple suspension to aortoinnominopexy. We found that the pericardiumattached to the aortoinnominate junction is strong and holds stitches well. The procedure is performed through a short right thoracotomy incision. The right lobe of the thymus is mobilized, the pericardium is opened, and a strip is left at the base of the innominate artery (Fig. 1). Three U stitches with pledgets, placed parallel to each other through the pericardium, are passed through the sternal periosteum and tied over pledgets. This effectively pulls the innominate artery and distal ascending aorta away from the trachea. With the current technique, we have not seen disruption of the repair encountered with simple suspension.

View larger version (24K): [in this window] [in a new window]   Fig. 1. A, Incision on the pericardium at the aortoinnominate junction is indicated.B,Three U stitches with pledgets are sutured into the sternal periosteum and tied over pledgets.C,The aortoinnominate junction is pulled away from the trachea.

1. Hawkins JA, Bailey WW, Clark SM. Innominate artery compression of the trachea: treatment by reimplantation of the innominate artery. J THORAC CARDIOVASC SURG 1992;103:678-82.[Abstract]
   
2. Backer CL, Holinger LD, Mavroudis C. Invited letter concerning: Innominate artery compression—division and reimplantation versus suspension. J THORAC CARDIOVASC SURG 1992;103:817-20.[Medline]
   
3. DeLeon SY, Idriss FS, Nikaidoh H, Muster A, Tucker GF. Anterior tracheal compression by displaced innominate artery [Abstract]. Proc Inst Med 1977;31:320.
   
4. Idriss FS, Nikaidoh H, DeLeon SY, Koopot R. Surgery for vascular anomalies causing obstruction of the trachea and esophagus. In: Congenital heart disease. Tucker BL, Lindesmith GG, eds. New York: Grune & Stratton, 1979:125-56.
   
5. Ardito JM, Ossoff RH, Tucker GF, DeLeon SY. Innominate artery compression of the trachea in infants with reflex apnea. Ann Otol Rhinol Laryngol 1980;89:401-5.[Medline]
   
6. Backer CL, Ilbawi MN, Idriss FS, DeLeon SY. Vascular anomalies causing tracheoesophageal compression: review of experience in children. J THORAC CARDIOVASC SURG 1989;98:725-31.[Abstract]
   

This article has been cited by other articles:

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This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Serafin Y. DeLeon Roque Pifarré Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by DeLeon, S. Y. Articles by Pifarré, R. Search for Related Content PubMed PubMed Citation Articles by DeLeon, S. Y. Articles by Pifarré, R.