Aortopexy for Tracheomalacia in Children: A Systematic Review and Meta-Analysis

Introduction: Aortopexy is the most common surgical option for the treatment of severe tracheomalacia (TM) in children. Despite being described over 75 years ago, several aspects of the procedure remain controversial. Materials and Methods: A systematic review of aortopexy was conducted following the PRISMA guidelines. All original articles describing at least one case of aortopexy performed in children for the treatment of TM were included. Patients' characteristics, surgical indications, approaches and details were collected. Outcomes were reviewed, and potential factors associated with procedural success were investigated. Results: Of 243 papers, 17 were included in this review, encompassing a total of 473 patients who underwent aortopexy. Of these, 65.3% were male, with a mean age at surgery of 12.2 months (5 days-18 years). Primary TM accounted for 7.9% of cases, while 92.1% were secondary to other anomalies, including esophageal atresia (54.1%), aberrant innominate artery (16.1%) and vascular rings (8.3%). There is a general consensus on the surgical indication for TM with severe symptoms, although the definition of severity is not well established. Overall success was 84%, but 40.8% of patients experienced some persistent symptoms. Sternotomy and thoracotomy were the most successful approaches (92.6% and 84.2%, respectively). Thoracoscopy had a similar success rate to sternotomy when pericardiotomy, thymectomy and pledgeted suture were performed (86.4% vs. 92.6% p = 0.41). Conclusions: Aortopexy is associated with good outcomes, but no evidence-based guidelines are currently available. Success appears to be associated with specific surgical steps rather than the surgical approach. Prospective studies are desirable for establishing precise guidelines.