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Technique to Avoid Innominate Artery Ligation and Perform an Anterior Mediastinal Tracheostomy for Residual Trachea of Less Than 5 cm

2007; Elsevier BV; Volume: 84; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2007.08.002

1552-6259

Abel Gómez-Caro, Josep María Gimferrer, Paolo Macchiarini,

Infectious Aortic and Vascular Conditions

A 47-year-old man was admitted with recurrent autolimited bleeding arising from a cervical tracheostoma made 2 years earlier during a total laryngectomy. Stomal recurrence of the past laryngeal cancer invading the neighboring innominate artery was diagnosed by angiographic computer tomography and bronchoscopic biopsies. The malignant tracheostoma-innominate fistula was approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, and manubriectomy. It was treated with an anterior mediastinal tracheostomy with omental major transposition, right latissimus dorsi myocutaneous flap for tissue coverage, and brachiocephalic artery rerouting with cadaveric homograft. The patient was discharged on postoperative day 14 after an uneventful postoperative course. A 47-year-old man was admitted with recurrent autolimited bleeding arising from a cervical tracheostoma made 2 years earlier during a total laryngectomy. Stomal recurrence of the past laryngeal cancer invading the neighboring innominate artery was diagnosed by angiographic computer tomography and bronchoscopic biopsies. The malignant tracheostoma-innominate fistula was approached through an extended transversal supraclavicular incision, bilateral hemiclaviculectomy, and manubriectomy. It was treated with an anterior mediastinal tracheostomy with omental major transposition, right latissimus dorsi myocutaneous flap for tissue coverage, and brachiocephalic artery rerouting with cadaveric homograft. The patient was discharged on postoperative day 14 after an uneventful postoperative course. Stomal recurrence after total laryngectomy occurs in about 5% to 15% of cases. Repetitive bleeding through the permanent tracheostoma usually reflects a tracheoinnominate fistulization [1Imauchi Y. Ito K. Takasago E. et al.Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx.Otolaryngol Head Neck Surg. 2002; 126: 63-66Crossref PubMed Scopus (42) Google Scholar]. This entity management represents a difficult challenge because of the vascular structures encompassing the upper aerodigestive system and destruction of surrounding previously irradiated tissues [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. However, selected patients can be managed successfully with an anterior mediastinal tracheostomy (AMT) with or without cervical exenteration. The innominate artery involvement can be solved by artery ligation [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 4Grillo H.C. Repair of tracheobranchicephalic artery fistula.in: Surgery of the trachea and bronchi. BC Decker, London, Ontario2003: 581-586Google Scholar], redirection along another path, or endoluminal stents placement [5Guibaud J.P. Laborde M.N. Dubrez J. et al.Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.Ann Vasc Surg. 2001; 15: 412-414Abstract Full Text PDF PubMed Scopus (5) Google Scholar]. In addition, tissue coverage such as with the major omentum or myocutaneous flaps should be used to bury deep structures [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar] and to replace deteriorated skin and soft tissues [6McCarthy C.M. Kraus D.H. Cordeiro P.G. Tracheostomal and cervical esophageal reconstruction with combined deltopectoral flap and microvascular free jejunal transfer after central neck exenteration.Plast Reconstr Surg. 2005; 115: 1304-1310Crossref PubMed Scopus (34) Google Scholar]. However, the condition sine qua non is to have a length of residual trachea of at least 4 to 5 cm [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar].We here present a technique to avoid innominate artery ligation and perform a safe AMT in patients whose residual intrathoracic trachea is less than 5 cm in length.TechniqueThe patient was placed supine with the neck hyperextend. The operative field extends from the chin to the pubis. Ventilation was assured by using an armored 8F cross-field tracheal cannula. A horizontal supraclavicular skin incision below the tracheostoma was performed to make the dissection of the previously irradiated structures belonging to the median thoracic outlet.The manubrium, clavicles heads, and first and second ventral ribs were resected to facilitate the approach to the retrosternal diseased region and supraaortic vessels [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar]. After systemic administration of 2500 U of heparin, the innominate vein was sectioned not only for a better control of the proximal innominate artery but also to visualize the tumor recurrence, which was located on the right lateral aspect of the tracheostoma and involved the innominate artery. Stepwise dissection revealed a tumor-free innominate artery at its distal bifurcation and a mediastinal extension of the tumor to involve the right lateral wall over 3 to 4 cm, leaving only 3 cm of healthy residual airway. Because of this, we decided to perform an AMT and to control the aortic arch by associating a median sternotomy.The aortic arch was released carefully and the left carotid artery was taped and reflected to the left. The aortic arch was then clamped to include the takeoff of the innominate artery, followed by clamping of the right prescalenic subclavian and carotid arteries beyond the innominate artery bifurcation. The diseased innominate artery was en bloc resected, and its proximal stump sutured with a continuous 3-0 polypropylene suture (Fig 1).The previous tracheostoma and tumor-affected airway were then resected on a tumor-free margin on frozen section. Next, a cadaveric common iliac cryopreserved arterial allograft was interposed between the left carotid artery (end-to-side anastomosis) and innominate artery (end-to-end anastomosis) above the previously located cervical stoma using continuous 5-0 suture. The intrathoracic trachea was completely mobilized up to the carina, and a new tracheal stoma was remade leaving the membranous portion longer than the cartilaginous face [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. An omentum major transposition was made to separate the neo-stoma from the aortic arch and provide indirect vascularization.Because the residual trachea was only 3 cm long, we decided to use a right myocutaneous latissimus dorsi flap to anchor the neo-stoma, thereby reducing its tension [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] while providing it with further indirect vascularization and protection (Fig 2). The thoracodorsal artery and vein were identified and skeletonized, and the pedicled flap was tunneled beneath the right major pectoralis to reach the anterior mediastinal defect. A circular stoma was created by excision of the skin, fat, and muscle, avoiding injury of the vessels on the deep surface of the flap. Interrupted 3-0 polyglactin sutures were first placed through the tracheal rim, and then brought through the opening stomal of the flap. The flap was folded down with the sutures tied sequentially to appose the skin to the residual trachea. Absorbable sutures were placed circumferentially, between 1 or 1.5 cm of the remaining trachea hedge and muscular flap tissue to reduce tension of the tracheocutaneous anastomosis.Fig 2Mediastinal tracheal neo-stoma created between the residual 3-cm-long trachea and a circular incision made on the middle of the transposed right latissimus dorsi (LD) myocutaneous flap. Care must be maximally addressed to create the flap large enough to be able to fold it down in the mediastinum and the close defect. (* = Left hemiclaviculectomy; MS = median sternotomy.)View Large Image Figure ViewerDownload (PPT)Finally, the skin was anastomosed to the trachea with interrupted 4-0 polyglactin suture. Mediastinal, cervical, and abdominal drains were placed as usual. The patient was extubated 24 hours later and discharged without anticoagulation treatment uneventfully on postoperative day 14. Twelve months later, a computed tomography angiography study revealed the patency of the cryopreserved allograft and no evidence of tumor recurrence.CommentThe surgical management described here presents several advantages compared with more conservative methods and appears to open the door to new considerations of the field of anterior mediastinal tracheostomy.First, the use of cryopreserved arterial allografts may avoid the unnecessary ligation of the innominate artery, preventing any early or late neurologic affection [8McCready R.A. Bryant M.A. Divelbiss J.L. et al.Arterial infections in the new millenium: an old problem revisited.Ann Vasc Surg. 2006; 20: 590-595Abstract Full Text Full Text PDF PubMed Google Scholar]. Cryopreserved arterial allografts remain infection-free and do not need long-term anticoagulation therapy, which further increases their clinical application. Whether the allograft should be interposed between the residual distal innominate artery stump and the aortic arch or left carotid artery depends on the individual situation, although it would be reasonable to make an end-to-side interposition between the left carotid artery and distal innominate artery because this allows sufficient and safe distance from the neo-stoma.Second, anchoring the new tracheostoma into the middle mediastinum by transposing a latissimus dorsi myocutaneous flap may extend the indication of ATM to include patients whose residual trachea is even less than 5 cm long [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. Moreover, the use of a remote transposed viable myocutaneous flap may provides the opportunity to (1) perform the new tracheostoma without tension, (2) avoid any pressure necrosis, and (3) encompass the neo-stoma with viable, not previously irradiated tissues. This is in contrast to Maigpan and colleagues [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] who proposed the pectoralis major flap; however, this muscle may be frequently irradiated and if so, would have reduced coverage and healing capacity.In conclusion, the presented technique may represent a further evolution of the AMT described by Grillo [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 4Grillo H.C. Repair of tracheobranchicephalic artery fistula.in: Surgery of the trachea and bronchi. BC Decker, London, Ontario2003: 581-586Google Scholar] and Orringer [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar] because it avoids unnecessary ligation of the innominate artery and extends the indication to this surgery to include patients with less than 5 cm of residual trachea. Stomal recurrence after total laryngectomy occurs in about 5% to 15% of cases. Repetitive bleeding through the permanent tracheostoma usually reflects a tracheoinnominate fistulization [1Imauchi Y. Ito K. Takasago E. et al.Stomal recurrence after total laryngectomy for squamous cell carcinoma of the larynx.Otolaryngol Head Neck Surg. 2002; 126: 63-66Crossref PubMed Scopus (42) Google Scholar]. This entity management represents a difficult challenge because of the vascular structures encompassing the upper aerodigestive system and destruction of surrounding previously irradiated tissues [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. However, selected patients can be managed successfully with an anterior mediastinal tracheostomy (AMT) with or without cervical exenteration. The innominate artery involvement can be solved by artery ligation [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 4Grillo H.C. Repair of tracheobranchicephalic artery fistula.in: Surgery of the trachea and bronchi. BC Decker, London, Ontario2003: 581-586Google Scholar], redirection along another path, or endoluminal stents placement [5Guibaud J.P. Laborde M.N. Dubrez J. et al.Surgical repair of an aneurysm of the innominate artery with fistulization into the trachea.Ann Vasc Surg. 2001; 15: 412-414Abstract Full Text PDF PubMed Scopus (5) Google Scholar]. In addition, tissue coverage such as with the major omentum or myocutaneous flaps should be used to bury deep structures [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar] and to replace deteriorated skin and soft tissues [6McCarthy C.M. Kraus D.H. Cordeiro P.G. Tracheostomal and cervical esophageal reconstruction with combined deltopectoral flap and microvascular free jejunal transfer after central neck exenteration.Plast Reconstr Surg. 2005; 115: 1304-1310Crossref PubMed Scopus (34) Google Scholar]. However, the condition sine qua non is to have a length of residual trachea of at least 4 to 5 cm [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. We here present a technique to avoid innominate artery ligation and perform a safe AMT in patients whose residual intrathoracic trachea is less than 5 cm in length. TechniqueThe patient was placed supine with the neck hyperextend. The operative field extends from the chin to the pubis. Ventilation was assured by using an armored 8F cross-field tracheal cannula. A horizontal supraclavicular skin incision below the tracheostoma was performed to make the dissection of the previously irradiated structures belonging to the median thoracic outlet.The manubrium, clavicles heads, and first and second ventral ribs were resected to facilitate the approach to the retrosternal diseased region and supraaortic vessels [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar]. After systemic administration of 2500 U of heparin, the innominate vein was sectioned not only for a better control of the proximal innominate artery but also to visualize the tumor recurrence, which was located on the right lateral aspect of the tracheostoma and involved the innominate artery. Stepwise dissection revealed a tumor-free innominate artery at its distal bifurcation and a mediastinal extension of the tumor to involve the right lateral wall over 3 to 4 cm, leaving only 3 cm of healthy residual airway. Because of this, we decided to perform an AMT and to control the aortic arch by associating a median sternotomy.The aortic arch was released carefully and the left carotid artery was taped and reflected to the left. The aortic arch was then clamped to include the takeoff of the innominate artery, followed by clamping of the right prescalenic subclavian and carotid arteries beyond the innominate artery bifurcation. The diseased innominate artery was en bloc resected, and its proximal stump sutured with a continuous 3-0 polypropylene suture (Fig 1).The previous tracheostoma and tumor-affected airway were then resected on a tumor-free margin on frozen section. Next, a cadaveric common iliac cryopreserved arterial allograft was interposed between the left carotid artery (end-to-side anastomosis) and innominate artery (end-to-end anastomosis) above the previously located cervical stoma using continuous 5-0 suture. The intrathoracic trachea was completely mobilized up to the carina, and a new tracheal stoma was remade leaving the membranous portion longer than the cartilaginous face [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. An omentum major transposition was made to separate the neo-stoma from the aortic arch and provide indirect vascularization.Because the residual trachea was only 3 cm long, we decided to use a right myocutaneous latissimus dorsi flap to anchor the neo-stoma, thereby reducing its tension [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] while providing it with further indirect vascularization and protection (Fig 2). The thoracodorsal artery and vein were identified and skeletonized, and the pedicled flap was tunneled beneath the right major pectoralis to reach the anterior mediastinal defect. A circular stoma was created by excision of the skin, fat, and muscle, avoiding injury of the vessels on the deep surface of the flap. Interrupted 3-0 polyglactin sutures were first placed through the tracheal rim, and then brought through the opening stomal of the flap. The flap was folded down with the sutures tied sequentially to appose the skin to the residual trachea. Absorbable sutures were placed circumferentially, between 1 or 1.5 cm of the remaining trachea hedge and muscular flap tissue to reduce tension of the tracheocutaneous anastomosis.Finally, the skin was anastomosed to the trachea with interrupted 4-0 polyglactin suture. Mediastinal, cervical, and abdominal drains were placed as usual. The patient was extubated 24 hours later and discharged without anticoagulation treatment uneventfully on postoperative day 14. Twelve months later, a computed tomography angiography study revealed the patency of the cryopreserved allograft and no evidence of tumor recurrence. The patient was placed supine with the neck hyperextend. The operative field extends from the chin to the pubis. Ventilation was assured by using an armored 8F cross-field tracheal cannula. A horizontal supraclavicular skin incision below the tracheostoma was performed to make the dissection of the previously irradiated structures belonging to the median thoracic outlet. The manubrium, clavicles heads, and first and second ventral ribs were resected to facilitate the approach to the retrosternal diseased region and supraaortic vessels [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar]. After systemic administration of 2500 U of heparin, the innominate vein was sectioned not only for a better control of the proximal innominate artery but also to visualize the tumor recurrence, which was located on the right lateral aspect of the tracheostoma and involved the innominate artery. Stepwise dissection revealed a tumor-free innominate artery at its distal bifurcation and a mediastinal extension of the tumor to involve the right lateral wall over 3 to 4 cm, leaving only 3 cm of healthy residual airway. Because of this, we decided to perform an AMT and to control the aortic arch by associating a median sternotomy. The aortic arch was released carefully and the left carotid artery was taped and reflected to the left. The aortic arch was then clamped to include the takeoff of the innominate artery, followed by clamping of the right prescalenic subclavian and carotid arteries beyond the innominate artery bifurcation. The diseased innominate artery was en bloc resected, and its proximal stump sutured with a continuous 3-0 polypropylene suture (Fig 1). The previous tracheostoma and tumor-affected airway were then resected on a tumor-free margin on frozen section. Next, a cadaveric common iliac cryopreserved arterial allograft was interposed between the left carotid artery (end-to-side anastomosis) and innominate artery (end-to-end anastomosis) above the previously located cervical stoma using continuous 5-0 suture. The intrathoracic trachea was completely mobilized up to the carina, and a new tracheal stoma was remade leaving the membranous portion longer than the cartilaginous face [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. An omentum major transposition was made to separate the neo-stoma from the aortic arch and provide indirect vascularization. Because the residual trachea was only 3 cm long, we decided to use a right myocutaneous latissimus dorsi flap to anchor the neo-stoma, thereby reducing its tension [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] while providing it with further indirect vascularization and protection (Fig 2). The thoracodorsal artery and vein were identified and skeletonized, and the pedicled flap was tunneled beneath the right major pectoralis to reach the anterior mediastinal defect. A circular stoma was created by excision of the skin, fat, and muscle, avoiding injury of the vessels on the deep surface of the flap. Interrupted 3-0 polyglactin sutures were first placed through the tracheal rim, and then brought through the opening stomal of the flap. The flap was folded down with the sutures tied sequentially to appose the skin to the residual trachea. Absorbable sutures were placed circumferentially, between 1 or 1.5 cm of the remaining trachea hedge and muscular flap tissue to reduce tension of the tracheocutaneous anastomosis. Finally, the skin was anastomosed to the trachea with interrupted 4-0 polyglactin suture. Mediastinal, cervical, and abdominal drains were placed as usual. The patient was extubated 24 hours later and discharged without anticoagulation treatment uneventfully on postoperative day 14. Twelve months later, a computed tomography angiography study revealed the patency of the cryopreserved allograft and no evidence of tumor recurrence. CommentThe surgical management described here presents several advantages compared with more conservative methods and appears to open the door to new considerations of the field of anterior mediastinal tracheostomy.First, the use of cryopreserved arterial allografts may avoid the unnecessary ligation of the innominate artery, preventing any early or late neurologic affection [8McCready R.A. Bryant M.A. Divelbiss J.L. et al.Arterial infections in the new millenium: an old problem revisited.Ann Vasc Surg. 2006; 20: 590-595Abstract Full Text Full Text PDF PubMed Google Scholar]. Cryopreserved arterial allografts remain infection-free and do not need long-term anticoagulation therapy, which further increases their clinical application. Whether the allograft should be interposed between the residual distal innominate artery stump and the aortic arch or left carotid artery depends on the individual situation, although it would be reasonable to make an end-to-side interposition between the left carotid artery and distal innominate artery because this allows sufficient and safe distance from the neo-stoma.Second, anchoring the new tracheostoma into the middle mediastinum by transposing a latissimus dorsi myocutaneous flap may extend the indication of ATM to include patients whose residual trachea is even less than 5 cm long [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. Moreover, the use of a remote transposed viable myocutaneous flap may provides the opportunity to (1) perform the new tracheostoma without tension, (2) avoid any pressure necrosis, and (3) encompass the neo-stoma with viable, not previously irradiated tissues. This is in contrast to Maigpan and colleagues [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] who proposed the pectoralis major flap; however, this muscle may be frequently irradiated and if so, would have reduced coverage and healing capacity.In conclusion, the presented technique may represent a further evolution of the AMT described by Grillo [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 4Grillo H.C. Repair of tracheobranchicephalic artery fistula.in: Surgery of the trachea and bronchi. BC Decker, London, Ontario2003: 581-586Google Scholar] and Orringer [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar] because it avoids unnecessary ligation of the innominate artery and extends the indication to this surgery to include patients with less than 5 cm of residual trachea. The surgical management described here presents several advantages compared with more conservative methods and appears to open the door to new considerations of the field of anterior mediastinal tracheostomy. First, the use of cryopreserved arterial allografts may avoid the unnecessary ligation of the innominate artery, preventing any early or late neurologic affection [8McCready R.A. Bryant M.A. Divelbiss J.L. et al.Arterial infections in the new millenium: an old problem revisited.Ann Vasc Surg. 2006; 20: 590-595Abstract Full Text Full Text PDF PubMed Google Scholar]. Cryopreserved arterial allografts remain infection-free and do not need long-term anticoagulation therapy, which further increases their clinical application. Whether the allograft should be interposed between the residual distal innominate artery stump and the aortic arch or left carotid artery depends on the individual situation, although it would be reasonable to make an end-to-side interposition between the left carotid artery and distal innominate artery because this allows sufficient and safe distance from the neo-stoma. Second, anchoring the new tracheostoma into the middle mediastinum by transposing a latissimus dorsi myocutaneous flap may extend the indication of ATM to include patients whose residual trachea is even less than 5 cm long [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar]. Moreover, the use of a remote transposed viable myocutaneous flap may provides the opportunity to (1) perform the new tracheostoma without tension, (2) avoid any pressure necrosis, and (3) encompass the neo-stoma with viable, not previously irradiated tissues. This is in contrast to Maigpan and colleagues [7Maipang T. Singha S. Panjapiyakul C. Totemchokchyakarn P. Mediastinal tracheostomy.Am J Surg. 1996; 171: 581-586Abstract Full Text PDF PubMed Scopus (14) Google Scholar] who proposed the pectoralis major flap; however, this muscle may be frequently irradiated and if so, would have reduced coverage and healing capacity. In conclusion, the presented technique may represent a further evolution of the AMT described by Grillo [2Grillo H.C. Mathisen D.J. Cervical exenteration.Ann Thorac Surg. 1990; 49: 401-408Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 4Grillo H.C. Repair of tracheobranchicephalic artery fistula.in: Surgery of the trachea and bronchi. BC Decker, London, Ontario2003: 581-586Google Scholar] and Orringer [3Orringer M.B. Anterior mediastinal tracheostomy with and without cervical exenteration.Ann Thorac Surg. 1992; 54: 628-636Abstract Full Text PDF PubMed Scopus (28) Google Scholar] because it avoids unnecessary ligation of the innominate artery and extends the indication to this surgery to include patients with less than 5 cm of residual trachea.