Left Mainstem Bronchus Compression by Descending Aorta in Tracheobronchomalacia: Protocol After Maximum Medical Therapy Has Not Met Goals
In a specific anatomical variant of tracheobronchomalacia, the descending aorta sits anterior to the spine and traps the mid-portion of the left mainstem bronchus between itself and the pulmonary artery. When maximum medical therapy for mucociliary clearance has been exhausted without meeting airway and nutritional targets, a defined next-step protocol applies.
Clinical Scenario
When the descending aorta is located too far anteriorly, the mid-portion of the left mainstem bronchus (L2) can be trapped between the descending aorta and the pulmonary artery, resulting in bronchial narrowing. This posterior compression by an anteriorly displaced descending aorta is the anatomical driver of symptoms in this subgroup.
Previous Line — Goals Not Achieved
The prior intervention was maximum medical therapy aimed at optimizing mucociliary clearance. Escalation to this protocol is indicated when that approach has not achieved controlled airway secretions and respiratory infections, or has not reached optimum nutrition with at least two weeks of adequate growth and positive nitrogen balance.
Next Intervention (Partial Overview)
For this anatomical configuration, a posterior aortopexy — surgically repositioning the descending thoracic aorta relative to the spine to relieve bronchial compression — is described as the indicated approach. The complete procedural technique, sequencing, and indications are contained in the full protocol.
Clinical Goal
Greater than 50% airway patency at minus 50 mmHg suction (Munoz maneuver).
References
DOI: 10.1016/j.sempedsurg.2021.151062
If the descending aorta is located too far anteriorly, the mid-portion of the left mainstem bronchus (L2) can be trapped between the descending aorta and pulmonary artery, resulting in narrowing the bronchus (Fig. 4).
A descending aorta located anterior to the spine can cause posterior compression on the mid-portion of the left mainstem bronchus.
Posterior descending aortopexy has been described to reduce left mainstem bronchus compression from descending aorta.
In such cases, a posterior descending aortopexy is often performed to secure the descending thoracic aorta to the side of the spine as posteriorly as necessary to relieve the left mainstem bronchus compression between the descending aorta posteriorly and the pulmonary artery anteriorly.
Our goal is greater than 50% airway patency at minus 50mmHg suction applied to the airways.
View source ↗