Tracheoplasty for complex low tracheal stenosis via cervicosternal approach with partial sternotomy: case report

Abstract

Background: Acquired tracheal stenosis is associated with prolonged endotracheal intubation and/or tracheostomy. Complex stenoses—especially distal lesions near the carina with cartilaginous deformity and critical luminal narrowing—often require definitive surgical management, as endoscopic strategies in benign disease may be associated with recurrence and device-related complications. Case presentation: A 32-year-old male with a remote history of severe burns, prolonged mechanical ventilation and long-term tracheostomy (approximately one year) developed progressive dyspnea, hypoxemia, biphasic stridor, and intermittent cyanotic episodes. He was initially treated for respiratory infection with partial improvement followed by clinical deterioration. Computed tomography and diagnostic bronchoscopy demonstrated severe distal tracheal stenosis with structural involvement (cartilaginous ring deformity and intraluminal wall protrusion), with critical caliber reduction (80–88%) in the distal trachea near the carina. Given the distal location, complex morphology, and limited suitability for stenting in benign stenosis, definitive surgical reconstruction was selected. Management and outcomes: After clinical optimization and treatment of the concomitant infectious component, tracheal resection and reconstruction were performed using a combined cervical approach with partial sternotomy to improve exposure of the distal trachea. Circumferential resection of the stenotic segment and end-to-end anastomosis were completed. A chin-to-chest “guardian stitch” was applied to reduce anastomotic tension during the early healing phase. The postoperative course was favorable. On postoperative day eight, control CT showed an adequate tracheal lumen and significant left lung atelectasis. Diagnostic/therapeutic bronchoscopy documented approximately 60% tracheal lumen with an intact endoluminal anastomosis and abundant whitish secretions in the left tracheobronchial tree: lavage and suctioning restored segmental patency without complications. Conclusions: Complex distal tracheal stenosis following airway instrumentation can be effectively managed with segmental resection and primary end-to-end anastomosis. A cervical-sternal approach with partial sternotomy provides safe exposure for distal lesions near the carina, and early therapeutic bronchoscopy can treat secretion-related atelectasis without compromising anastomotic integrity.