Aortic elongation with prosthetic graft followed by aortopexy for fixed left main bronchial compression in an adolescent with severe thoracic deformity: A case report

Abstract

Airway compression in older children is uncommon and becomes more challenging when thoracic deformities alter aortic anatomy. A 16-year-old girl with severe scoliosis and chronic bedridden status presented with progressive respiratory distress caused by compression of the left main bronchus between the ascending aorta and a right-sided descending aorta. As conventional aortopexy alone was unlikely to achieve adequate decompression, aortic elongation using a prosthetic graft was performed to reposition the descending aorta posteriorly, followed by aortopexy. Postoperative imaging confirmed complete bronchial decompression, and the patient’s respiratory symptoms resolved.

Airway compression due to vascular structures is most commonly observed in infants with congenital anomalies or tracheomalacia. Aortopexy effectively relieves dynamic airway collapse in young children, as their vascular tissues are soft and mobile. Anatomically, aortopexy involves suturing the anterior wall of the aorta to the posterior sternum or adjacent tissues to shift the aorta anteriorly and enlarge the airway space. However, in older children and adolescents, reduced aortic elasticity and mobility may limit the effectiveness of standard aortopexy.

In addition, certain anatomical conditions, such as thoracic scoliosis, predispose patients to vascular airway compression and may further reduce the efficacy of aortopexy. Left-convex thoracic scoliosis, characterized by leftward convexity in the upper thorax and rightward convexity in the lower thorax, along with rightward vertebral rotation, is less common than the typical right-convex adolescent pattern. In these cases, the aorta may resemble a left aortic arch with a right-sided descending aorta, making conventional aortopexy insufficient for adequate decompression.

Here, we report a case of left main bronchial compression associated with this complex anatomy that was successfully treated with aortic elongation using a prosthetic graft followed by aortopexy. This manuscript was prepared following the CAse REport guidelines (https://www.care-statement.org).

Case report

A 16-year-old woman with cerebral palsy, neonatal intracranial hemorrhage, and long-term bedridden status developed severe scoliosis and pectus excavatum. Chest radiography revealed left-convex thoracic scoliosis with right vertebral rotation, resulting in an S-shaped deformity (Fig 1).

Fig 1.

Chest radiograph obtained on admission demonstrating left-convex thoracic scoliosis with right vertebral rotation, resulting in an S-shaped thoracic deformity.

She had been taking oral nutrition at home but experienced recurrent respiratory infections over the preceding 6 months. One week before transfer, she was admitted to a local hospital with hypoxemia, where bronchitis and asthma exacerbation were diagnosed. Despite inhaled corticosteroids, her respiratory status deteriorated, leading to progressive left lung atelectasis and, necessitating intubation, after which, the atelectasis improved.

Bronchoscopy revealed severe external compression of the left main bronchus, and contrast-enhanced computed tomography (CT) demonstrated that the descending aorta, displaced anteriorly and laterally by thoracic deformity, compressed the left main bronchus between the aorta and chest wall (Fig 2). Preoperative bronchoscopy clearly demonstrated severe external compression of the left main bronchus between the ascending and descending aorta, consistent with CT findings. Owing to the fixed and structural nature of the compression, she was transferred to our institution for surgical management.

Fig 2.

Preoperative imaging and bronchoscopic findings. A, Posterior three-dimensional (3D) computed tomography (CT) reconstruction demonstrating the thoracic aorta and severe narrowing of the left main bronchus (red arrow). B, Bronchoscopic view demonstrating marked external compression of the left main bronchus (red arrow). The asterisk (∗) indicates the location of the descending aorta causing the extrinsic compression. C, Axial view demonstrating compression of the left main bronchus (red arrow) between the sternum and the displaced descending aorta (∗).

Given her age, body size, and rigid thoracic anatomy, conventional aortopexy alone was deemed insufficient to create adequate space between the aorta and bronchus. A left fifth intercostal thoracotomy was performed. The lung was gently displaced caudally, and the mediastinal pleura overlying the descending aorta was divided to expose the vessel. A fibrous remnant of the ductus arteriosus was identified and divided to allow adequate mobilization of the distal arch. After systemic heparinization, cardiopulmonary bypass was established using descending aortic perfusion and pulmonary artery drainage to maintain distal organ perfusion without cardiac arrest. The descending aorta was clamped at the distal arch and again approximately 5 cm caudally. The segment between the clamps was divided, and an 8 cm length of a 16 mm prosthetic tube graft (J-graft, Japan Lifeline Inc) was inserted with end-to-end anastomoses to elongate and posteriorly reposition the descending aorta. This elongation created sufficient space between the aorta and the left main bronchus.

To prevent recurrent compression, the grafted segment of the aorta was sutured to the parietal pleura and intercostal fascia at three points using pledget-reinforced stitches, securing the elongated aorta in a stable anterior position (Fig 3). She was successfully extubated after airway edema had resolved. Because she had severe motor and intellectual disabilities with generalized muscle weakness, continuous positive airway pressure was applied to support her respiratory effort despite adequate airway patency. Chest radiography demonstrated increased lung aeration, and postoperative CT confirmed complete decompression of the left main bronchus (Fig 4). Her respiratory condition remained stable until transfer to the rehabilitation facility.

Fig 3.

Intraoperative findings. A, After left fifth intercostal thoracotomy, the lung was displaced caudally and the mediastinal pleura overlying the descending aorta was divided to expose the vessel. B, A fibrous remnant of the ductus arteriosus was divided to mobilize the distal arch, after which the descending aorta was clamped at the distal arch and again approximately 5 cm caudally. The segment between the clamps was then divided. C, An 8-cm length of a 16-mm prosthetic tube graft (J graft, Japan Lifeline Inc) was inserted with end-to-end anastomoses, and sutures were placed in preparation for fixation of the elongated aorta. D, The grafted segment was then sutured to the parietal pleura and intercostal fascia at three points using pledget-reinforced stitches, securing the elongated aorta in a stable anterior position.

Fig 4.

Postoperative contrast-enhanced computed tomography (CT). A, Posterior three-dimensional (3D) reconstruction demonstrating elongation of the descending aorta with a prosthetic graft (solid white arrow) and the site of aortopexy (dotted white arrow). The previously compressed left main bronchus is now fully decompressed (red arrow). B, Axial CT view demonstrating complete resolution of the left main bronchial compression (red arrow). The asterisk (∗) indicates the descending aorta, which had been previously caused extrinsic compression before surgical elongation and fixation.

Discussion

In this patient, left-convex thoracic scoliosis with right vertebral rotation created an S-shaped deformity that altered the course of the aorta (Fig 1). The patient’s left-convex thoracic curve, which is uncommon,¹ predisposed her to developing a left aortic arch with a right-sided descending aorta.² This abnormal configuration placed the descending aorta directly against the left main bronchus, resulting in fixed compression.³

Under these circumstances, conventional aortopexy would have applied traction to the descending aorta segment responsible for the obstruction,1, 2, 3 making adequate decompression unlikely. The limited flexibility of the adolescent aorta further restricted safe anterior mobilization.⁴ Therefore, the patient underwent graft interposition from the distal left subclavian artery to the descending aorta to allow controlled elongation and redirection of the aortic course without excessive tension, which reliably relieved her bronchial stenosis (Fig 4).

Cardiopulmonary bypass was necessary to ensure hemodynamic stability during precise reconstruction of the distal arch and descending aorta, given the patient’s compromised airway, which posed a risk of intraoperative ventilation instability. Multimodal imaging, including CT and bronchoscopy, was crucial for identifying the compression mechanism and confirming postoperative improvement (Fig 4).

This case illustrates that severe thoracic deformity can significantly alter aortic positioning and lead to fixed bronchial compression in older pediatric patients. When standard aortopexy is inadequate, aortic reconstruction with graft elongation may serve as an effective adjunctive strategy.

This report highlights a rare anatomical mechanism of fixed left main bronchial compression and demonstrates the effectiveness of aortic elongation with graft interposition. However, as a single case, its generalizability is limited.

Written informed consent for publication was obtained from the patient and the patient’s guardian.

Conclusions

This case demonstrates that severe thoracic deformity can alter aortic positioning and cause fixed bronchial compression in adolescents, highlighting that conventional aortopexy alone may be insufficient in such anatomically complex situations. Aortic elongation with prosthetic graft reconstruction may serve as an effective adjunct when conventional aortopexy alone is insufficient for durable airway decompression.

Funding

No funding was provided.

Disclosures

The authors have no competing interests.