Aortopexy for Innominate Artery Compression of the Trachea

1. Anesthesia

1. General anesthesia is given via mask induction in the operating room.
2. Due to average age of patient and the tenuous nature of the airway, all anesthesia is given in the operating room due to safety considerations.
3. The Pediatric Intensive Care Unit should be made aware of patient so they are prepared to receive them postoperatively.

2. Patient Positioning

4. Patient is placed in left lateral decubitus position at an approximately 30-degree angle.
5. All bony prominences are well padded.

3. Exposure and surgical approach

6. A bronchoscopy is performed before thoracotomy to identify the level of tracheal obstruction.
7. A thoracotomy incision made in third right anterior intercostal space.
8. Pectoral muscles are incised medially and split towards lateral end of incision.
9. Perichondrium and periosteum of rib are incised and separated from the cartilage and bone respectively.
10. A chest retractor placed.
11. The lung is retracted with a moist wet sponge.
12. The thymus is mobilized away from the superior vena cava (on the right), taking care not to injure the phrenic nerve.
13. The ipsilateral thymic lobe is resected, exposing the innominate artery and vein and the aorta.
14. The ipsilateral pericardium is incised and opened to expose roots of great vessels.

4. Optimal Site for Placement of Aortopexy Sutures

16. While bronchoscopy is performed, the aorta is lifted manually in several places to identify the optimal site for placement of the pexy sutures.

5. Placement of Sutures in Aorta

17. Once optimal site is identified, three pexy sutures are placed through pericardial reflection and aortic adventitia at the base of the innominate artery.
    • Care must be taken to NOT place suture through tunica media of the aortic wall.
18. Sutures are then placed through posterior periosteum of sternum.
19. Under direct bronchoscopy, the innominate artery is elevated and the three pexy sutures are tied down to approximate the innominate artery to the sternum, thus elevating it off of the trachea.

6. Closure

21. The wound is closed in layers, with specific attention paid to the fascia of the pectoralis major to ensure no problems with muscle strength long term.
22. Subcutaneous tissues are closed using a 3-0 Vicryl suture.
23. Skin is reapproximated using a 5-0 absorbable monofilament suture such as Monocryl.
24. Normally a chest drain is not needed if the operative field is dry.

7. Postoperative care

25. The patient is encouraged to feed orally after surgery and is kept in the Pediatric Intensive Care Unit for postoperative observation.
26. If the patient feeds well and the respiratory symptoms improve, the patient may be discharged the next day.