The role of airway stents in the management of pediatric tracheal, carinal, and bronchial disease.

OBJECTIVE: A variety of stents are available to aid in the management of complex tracheal, carinal and bronchial stenoses. We reviewed our multi-institutional experience with airway stents in children. METHODS: Thirty-three children (age, 13 days-18 years) from four institutions have had a total of 40 stents placed to aid in the management of complex airway stenoses. Three stent types were utilized: 29 silastic stents, five expandable metal stents and six customized carinal stents (four patients had two stents and one patient had four stents). Thirty children had tracheal stents, six children had bronchial stents, and two infants had carinal stents (three children had stenting of more than one area and two had stenting of all three locations). Twenty-eight patients (age, 5 months-18 years; mean, 8.06 years; SEM, 1.13 years) had stents placed after a variety of airway reconstructive procedures. Four underwent stenting in a non-operative setting and one as preoperative stabilization. RESULTS: Twenty-seven patients survived. One patient died early due to bleeding. Five patients died late: two due to bleeding, one from mediastinitis, and two patients with functional airways died late from unrelated problems. Complications are related to stent type and location. Carinal stents can migrate; several techniques are available to help manage this problem. Wire stents are essentially non-removable requiring periodic dilation. Silastic stents stimulate granulation tissue formation requiring periodic bronchoscopic removal. CONCLUSION: Tracheal stenting can aid in the management of pediatric airway problems. Complications are common, but can be managed with appropriate intervention.

Congenital Heart Surgery Nomenclature and Database Project: atrial septal defect.

The extant nomenclature for atrial septal defect (ASD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: ventricular septal defect.

The extant nomenclature for ventricular septal defect (VSD) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Four basic VSD types are described: Subarterial, Perimembranous, Inlet, and Muscular. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analysis. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: atrioventricular canal defect.

The extant nomenclature for atrioventricular (AV) canal/atrioventricular septal defect is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. The three general categories are: partial AV canal (ostium primum defect), transitional (intermediate) AV canal, and complete AV canal. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Congenital Heart Surgery Nomenclature and Database Project: aortopulmonary window.

The extant nomenclature for aortopulmonary window (AP window) and pulmonary artery origin from ascending aorta (hemitruncus) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Tracheal allograft reconstruction: the total North American and worldwide pediatric experiences.

BACKGROUND: We reviewed both the North American and the total worldwide pediatric experience with tracheal allograft reconstruction as treatment for patients with long segment and recurrent tracheal stenosis. METHODS: The stenosed tracheal segment is opened to widely patent segments. The anterior cartilage is resected and the posterior trachealis muscle or tracheal wall remains. A temporary silastic intraluminal stent is placed and absorbable sutures secure the chemically preserved cadaveric trachea. After initial success with this technique in Europe, several North American centers have now performed the procedure. The cumulative North American experience includes 6 patients (3 adults and 3 children). Worldwide, more than 100 adults and 31 children, aged 5 months to 18 years, with severe long segment tracheal stenosis have undergone tracheal allograft reconstruction. RESULTS: In North America, 5 of 6 patients have survived, with one early death due to bleeding from a tracheal-innominate artery fistula in a previously irradiated neck. Worldwide, 26 children survived (26 of 31 = 84%) with follow-up from 5 months to 14 years. Only 1 of 26 pediatric survivors (1 of 26 = 3.8%) had a tracheostomy. CONCLUSIONS: Tracheal allograft reconstruction demonstrates encouraging short- to medium-term results for patients with complex tracheal stenosis. Allograft luminal epithelialization supports the expectation of good long-term results.

Allograft replacement of the aortic valve versus the miniroot and valve.

Between February 1986 and April 1992, 27 patients ranging in age from 8 to 65 years (median, 18 years) underwent allograft replacement of the aortic valve with one death (operative mortality, 3.7%). The indications for operation were aortic regurgitation in 14 patients, aortic stenosis in 7, aortic stenosis/regurgitation in 4, and endocarditis in 2. Associated lesions included annuloectasia in 4 patients (1 with Marfan's syndrome), sinus of Valsalva aneurysm in 3, coronary artery disease in 4, and ventricular septal defect in 2. The freehand technique was used in 12 patients and the miniroot replacement in 15 patients. The postoperative transvalvular gradient was 17 mm Hg in freehand valves and 7 mm Hg in the miniroot valves. Initial postoperative study showed no or trivial aortic regurgitation in all 26 survivors except 1 freehand patient who had mild aortic regurgitation. At late study up to 6 years postoperatively all 10 of our available freehand patients showed progressive regurgitation, and it was severe in 4 patients. By contrast only half of the miniroot patients showed progressive regurgitation, and in none was it severe. Allograft replacement of the aortic valve can be done in children and adults with low mortality rate, short hospital stay, and excellent early function. Subsequent follow-up studies suggest that the miniroot replacements are superior to the freehand valves with lower transvalvular gradients, less valvular regurgitation, and delayed progression of valvular regurgitation.

Intra-arterial streptokinase in the treatment of acute arterial thrombosis.

Streptokinase and catheter thrombectomy were retrospectively compared in 25 patients who presented with acute ischemia to investigate whether the use of intra-arterial streptokinase offers an advantage in the treatment of acute arterial or graft thrombosis. Streptokinase was used in all patients presenting with acute thrombosis unless the ischemic limb would not tolerate the time required for clot lysis. Complete thrombolysis was achieved in 47 per cent of the occlusions treated with streptokinase and initial limb salvage rate in 37 per cent of the patients. Subsequent surgical procedures were required in seven of eight patients with successful thrombolysis. Catheter thrombectomy reestablished vessel or graft patency in 86 per cent of the procedures and achieved initial limb salvage in 67 per cent of the patients. Long term (greater than six months) patency was achieved in 25 per cent of the patients treated with streptokinase and 44 per cent of the patients with catheter thrombectomy. Streptokinase did not prevent the need for further surgical intervention, improve early patency of these vessels or promote limb salvage when compared with that of catheter thrombectomy.