Surgical Approaches for Vascular-Related Aerodigestive Compression

Aerodigestive compression syndromes of vascular origin can be broadly classified based on congenital and acquired causes. Congenital causes include various types of arch anomalies (vascular rings including double arches, right aortic arch with aberrant left subclavian artery, circumflex aorta, etc.), arch branching anomalies (left aortic arch with aberrant right subclavian artery, innominate artery-related compression), aneurysms of either the aorta or main pulmonary artery or branch pulmonary arteries, and any combinations of these. Acquired causes of aerodigestive compression are mostly postsurgical, which is a distinct and challenging entity usually arising from arch reconstructive procedures, root amalgamation procedures, procedures involving the LeCompte maneuver, and procedures involving PDA stenting. When there are associated thoracic cage and vertebral anomalies, an additional layer of complexity is added to an already challenging problem. At Boston Children's Hospital, these patients are evaluated with a multidisciplinary team using diagnostic studies, including echocardiography, esophagram, computed tomographic angiography, and three-phase dynamic bronchoscopy for a thorough understanding of anatomic and physiologic complexities. Surgical correction to relieve compression requires an individualized plan for each patient, and 3D models are routinely employed. Posterior thoracotomy, sternotomy, and video-assisted thorocoscopy (VATs) are approaches to correct these problems with additional concomitant usage of aortopexy, tracheopexy, and localized or complete esophageal mobilization. Intraoperative bronchoscopy is widely used both for surgical planning and for confirmation of relief of compression.