Aortopexy means lifting anteriorly the aorta and suturing it to the posterior surface of the sternum

The aim of this paper is to evaluate and discuss the literature relating to indications, surgical details and clinical results of aortopexy, usually performed for tracheomalacia (TM).

TM is a localized or generalized weakness of the tracheal wall which creates airway obstruction resulting in different degrees of symptoms. It can be isolated or associated with other anomalies such as anterior vascular compression, oesophageal atresia (OA) with tracheo-oesophageal fistula (TOF) or gastro-oesophageal reflux (GOR). Although, in some cases, spontaneous improvement can occur, TM can also result in severe cough, respiratory distress episodes or “near-death” spells (acute life-threatening events, ALTE). Amongst several possible treatments, including tracheostomy and non invasive ventilation, airway stenting, and surgical approaches, aortopexy is a favoured option in many centres. As the anterior tracheal wall is attached through pre-tracheal fascia to the posterior aortic wall, the tracheal lumen is opened by aortopexy.

Despite this popularity, there is a surprising lack of evidence to support aortopexy as effective treatment for TM, and no randomized controlled trials have been published on this subject. Most papers report only small, single centre series.

Moreover, the term ‘aortopexy’ is rather generic and may describe many different approaches and different techniques. The approach to the aorta can be anterior, through a median full or limited sternotomy, possibly associated with cervical incision, lateral or anterolateral, from both sides of the thorax. More recently, thoracoscopic aortopexy has been described.

Materials and methods

A literature review was conducted on PubMed, using the search term “Aortopexy” without setting any temporal or other limits. Inclusion criteria for the review were papers written in English reporting more than one case of aortopexy. The references articles of the selected papers were screened and included if they met the inclusion criteria.

A total of 125 papers were identified, but only 40 papers met the inclusion criteria and thus form the subject of our review. The articles were classified according to the revised SIGN grading system, available on The following data have been retrieved from every paper included: demographics (number, sex and age of the patients), causes of TM, clinical data (symptoms, co-morbidities), diagnostic investigations, type of treatment (approach to aortopexy, other surgical procedures), outcome (complications, resolution of symptoms and length of follow up).

Results

Table 1 shows the list of the papers evaluated and the summary of the data retrieved. We analyzed 40 articles. Of these, 14 reported less than 10 patients, 13 papers between 10 and 20 patients and only 16 articles more than 20 patients.

A total of 758 patients (62% males) were affected with TM; 581 of them underwent aortopexy at a mean age of 10.5 months between 1968 and 2008. TM was associated with OA in 44% of patients; in 18% vascular rings or other anomalies of the heart or great vessels was reported; and in 16% there was right innominate artery compression. In 9% the TM was classified as idiopathic. The most frequent symptom was one or more episodes of ALTE (43%), followed by stridor (26%), recurrent pneumonias (21%), respiratory distress (14%), cough and/or wheezing (8%), dysphagia (4%) or impossibility to wean from mechanical ventilation (3.5%). In a population of patients with TM and innominate artery compression, the presenting symptom varied according to age, as small infants presented more frequently with ALTE or apnoeic episodes and older children with cough episodes. Among pre-operative investigations, bronchoscopy was performed in 98% of cases.

The surgical approach was mainly via thoracotomy; left anterior in 72% of cases, right anterior in 9% and muscle sparing in 2%. A median approach (partial or full sternotomy) was electively chosen in 15%. This solution was also adopted instead of another approach if another cardiovascular procedure had to be performed at the same time. In the largest series published, left thoracotomy and median sternotomy were compared and no differences have been found in terms of efficacy of the aortopexy. In 1% of patients a thoracoscopic aortopexy was performed. Intra-operative bronchoscopy was performed in 37% of cases to evaluate the resolution of the tracheal collapse during the maneuver, but the majority of the surgeons (58%) do not describe it as necessary. One of them reported using intra-operative bronchoscopy during sexy swiss girls profiles their initial experience but discarded it later on.