Internal Mammary Artery Compression After Pectus Excavatum Repair Does Not Increase Risk of Hemorrhagic Complications in Pediatric Patients

Abstract

Objectives: Minimal invasive repair of pectus excavatum (MIRPE) described by Nuss is the most popular correction nowadays of this deformity. During the introduction of the bars, they can hurt or compress the internal mammary arteries (IMA). The aim of this study was to observe the prevalence of IMA compression in children after MIRPE. Also, we examined if IMA obstruction increases the risk of complications at bar removal, and if these vascular changes are reversible.Materials and Methods: All patients operated on pectus excavatum in our tertiary pediatric surgical center between 2013 and 2019 were involved in the study. Data of age, sex, number of bars and characteristics of the deformity were examined. IMA flow was checked by Doppler ultrasound (DUS) after MIRPE and after bar removal, too.Results: Among 41 patients with mean age of 15.2 years there were 18 asymmetrical deformities, 23 sternal rotations. Mean pectus index was 4.01. After the Nuss procedure 7(9%) stenoses and 10(12%) occlusions of IMA were found on DUS. After bar removal 3 of 4 stenoses have resolved, but all examined occlusions (3/3) persisted. There were no complications during bar removals.Conclusion: IMA compression after MIRPE in children is uncommon, and is not influenced by severity of deformity. Obstruction of these vessels does not increase the risk of hemorrhagic complications at bar removal. Data of larger cohort are needed to determine reversibility of these changes.

Management of Internal Mammary Artery Injuries Associated With the Nuss Procedure

“…The reported overall complication rate is between 2 and 27%. 1,2 Complications are characterized as early or late complications with the most common complications being early pneumothorax or late bar shift. 3 Fortunately, the incidence of severe life-threatening complication is reported to be .1%.…”

“…3 Fortunately, the incidence of severe life-threatening complication is reported to be .1%. 1 Direct cardiac injury represents the majority of published severe complications; however, reports have been published describing internal mammary artery injury resulting in hemorrhage in the acute or chronic setting. 3,4 Here, we present 3 cases of internal mammary artery injury at various chronicity resulting in massive hemorrhage and subsequent management strategies.…”

“…1,2 Severe, life-threatening complication rates, however, are reported at .1% where injury to the heart, major vessels, lung, or diaphragm may occur. 1 There are few reports of acute or chronic injury to mammary arteries after MIRPE, but these complications do exist, typically in the delayed setting. [2][3][4] Early complication with pleural effusion is almost invariably due to hemothorax, but in most cases despite exploration, a bleeding source is not identified.…”

“…Pectus excavatum is the most common chest wall deformity occurring in approximately 1 in 400 live births with a male predominance. 1 First published in 1998 by Dr Nuss, the minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, has become the gold standard technique for the correction of pectus excavatum. Minimally invasive repair of pectus excavatum is regarded as a low-risk operation with ample literature supporting long-term efficacy and safety.…”

“…It is not, however, impervious to complication, with reported complication rates of 2-27%. 1,2 Severe, life-threatening complication rates, however, are reported at .1% where injury to the heart, major vessels, lung, or diaphragm may occur. 1 There are few reports of acute or chronic injury to mammary arteries after MIRPE, but these complications do exist, typically in the delayed setting.…”