Innominate artery transection for patients with severe chest deformity: optimal indication and timing.

PURPOSE: The innominate artery sometimes compresses the trachea, leading to tracheomalacia and highly fatal tracheoinnominate fistula in patients with severe chest deformity. This study is focused on the indication of innominate artery transection for the definitive treatment of these complications. PATIENTS AND METHODS: We retrospectively analyzed the medical records of eight patients who underwent transection of innominate artery. RESULTS: All patients had developed severe chest deformity and their symptoms were life-threatening anoxic spell or endotracheal hemorrhage. Bronchoscopy showed tracheomalacia with or without pulsatile granulations on the anterior wall of the trachea underlying the innominate artery. In six cases who had previously undergone tracheostomy or laryngotracheal separation, the tracheal tube tip made granulations or tracheoinnominate fistulas. In addition to transection of innominate artery, the tracheoinnominate fistula was closed in two cases and the artery was transposed in one. All patients survived without neurologic complications and airway symptoms postoperatively. CONCLUSIONS: For patients with severe chest deformity, innominate artery transection is indicated when they have tracheal compression by the artery and need to be intubated through the compressed part of trachea to secure the airway. This would be the best timing to schedule the prophylactic operation.

Minimally invasive innominate artery transection for tracheomalacia using 3-dimensional multidetector-row computed tomographic angiography: report of a case.

We successfully performed transection of the innominate artery in a patient with a neuromuscular disorder through minimally invasive access after confirming the anatomical relationships of the vessel using 3-dimensional multidetector-row computed tomographic angiography. A 16-year-old girl with spinal muscular atrophy type 1 had been on long-term mechanical ventilation with a tracheostomy. She had scoliosis and tracheomalacia. Bronchoscopy showed a flattened and narrow lower trachea and an anterior pulsatile compression by the innominate artery. She underwent transection of the innominate artery to prevent tracheoinnominate artery fistula formation. Based on preoperative 3-dimensional multidetector-row computed tomographic angiography images, the innominate artery was transected through a small transverse curvilinear skin incision just below the suprasternal notch and an oblique partial manubriotomy from the suprasternal notch to the first left intercostal space.

Long-term T-tube stenting as definitive treatment of severe acquired subglottic stenosis in children.

PURPOSE: We analyzed our results of long-term T-tube stenting for severe acquired subglottic stenosis secondary to prolonged endotracheal intubation in a neonatal period. MATERIALS AND METHODS: Twenty children treated with T-tube stenting since 1999 were retrospectively analyzed. T-tube stenting consisted of anterior cricoid split and placing silicon T-tube as a stent for expanded subglottic lumen. RESULTS: Fourteen of 20 patients were treated as an initial operation and 6 patients as an additional operation after other failed procedures. Decannulation was achieved in 8 (57.1%) of 14 children in the initial operation group and in 4 (66.7%) of 6 patients in the additional operation group. The average duration of T-tube stenting was 16.1 months in the initial group and 65.8 months in the additional group. Four of 20 patients continued to require T-tube stenting. In the other 4 patients, T-tubes were switched to tracheostomy tubes. The voice quality improved gradually after decannulation. CONCLUSION: T-tube stenting for severe acquired subglottic stenosis is recommended as a best available treatment in postoperative quality of life. T-tube stenting should be performed as the initial treatment because the time to decannulation was shorter than as an additional operation.

Can biliary atresia be diagnosed by ultrasonography alone?

BACKGROUND/PURPOSE: The triangular cord sign (TCS) is a specific ultrasonographic finding, reflecting a fibrotic mass at the porta hepatis in biliary atresia (BA). We evaluated whether BA can be diagnosed by ultrasonography alone using 3 findings: TCS, gallbladder length (GBL), and gallbladder contractility (GBC). METHODS: Subjects comprised 85 infants (median age, 47 days; range, 4-144 days) with cholestatic jaundice who underwent ultrasonographic examination for diagnosis between May 1996 and June 2006. Medical records were reviewed with regard to TCS, GBL, and GBC. Positive findings for BA included TCS >or=3 mm, GBL <15 mm, and GBC <68% (for < 12 weeks) or <25% (for >or=12 weeks). RESULTS: Biliary atresia was diagnosed in 48 patients surgically, with other cholestatic diseases diagnosed in the remaining 37 patients. Triangular cord sign was positive in 41 of 48 infants with BA and negative in 35 of 37 infants without BA. The 7 patients with BA who displayed negative results for TCS displayed positive findings for GBL or GBC. Positive predictive value in the diagnosis of BA was 98% if positive TCS was combined with abnormal gallbladder findings, whereas negative predictive value in diagnosis of BA was 100% if negative TCS was combined with findings of a normal gallbladder. CONCLUSIONS: Biliary atresia can be accurately diagnosed by ultrasonography using the findings of TCS combined with GBL and GBC.

Thoracic aneurysm expansion secondary to collateral supplies via thyrocervical trunk and intercostal arteries in a patient after thromboexclusion.

A case of thoraco-abdominal aortic aneurysm complicated after permanent clamping of the descending aorta (thromboexclusion) is reported. Angiographic and operative findings were: (1) a pseudo-aneurysm right at the distal anastomosis of previous intrathoracic bypass for pseudo-coarctation of the aorta filled by left ninth intercostal artery, which was supplied by the left internal thoracic artery; and (2) the cervical and thoracic spinal cord were supplied by the left vertebral artery and the mediastinal branch of the left thyrocervical trunk. This rare cause of a thoraco-abdominal aortic aneurysm and the significance of the subclavian artery as a source of spinal cord blood supply are discussed.