100. Development of a Preoperative Vascular Imaging Protocol for Planning of Supercharged Jejunal Conduits in Pediatric Esophageal Replacement

PURPOSE: Esophageal loss or long-segment injury requiring esophageal replacement in the pediatric population is challenging due to patient size and longevity. Each replacement conduit carries unique drawbacks including risk of aspiration with gastric pull-ups, hypomotility with colonic conduits, and unreliable blood supply for the jejunum. To maximize long-term success, our program favors the use of supercharged, pedicled jejunum conduits. The internal mammary vessels represent the primary target for recipient vessels. In order to optimize success, preoperative assessment of the mammary vessels and evaluation of alternative venous conduits including the cephalic (CV) and external jugular (EJ) veins is necessary. We report our early experience and impact on operative planning using preoperative CT angiogram/venogram of the chest and neck. METHODS: Eight patients underwent a CT angiogram of the chest/neck with arterial and venous phases for visualization of the internal mammary arteries (IMA) and veins (IMV), CVs, and EJs. The caliber/integrity of IMA/IMV were assessed to determine the initial side for exploration. The CVs and EJs were assessed as potential secondary/tertiary recipient veins. On the day of surgery, central line placement spared desired CV and IJ targets which were identified with ultrasound, marked, and prepped into the field. RESULTS: Between April 2023 and March 2024, 8 patients underwent supercharged jejunum for esophageal replacement with preoperative vascular imaging. The median age was 3.2 years (1.5-15.5). One patient underwent a previous sternotomy. Visualization of bilateral IMA was achieved in all patients. IMVs were visualized with lower resolution. One patient underwent exploration of mammary vessels bilaterally due to small vein caliber not appreciated on imaging. All 8 patients underwent supercharge to the IMA. Six patients underwent venous anastomosis to the IMV (median coupler size: 1.5mm). In two patients the CV was used due to insufficient IMV size (median coupler size: 2.5mm). Ten out of 16 visualized CVs were present and sufficient. Two patients lacked CVs bilaterally. Fifteen of 16 EJs were present and sufficient. CONCLUSION: Preoperative CTA/CTV is helpful in preparation for supercharged jejunal conduits for esophageal replacement. Imaging reliably demonstrated patency and caliber of the IMAs, but IMV imaging was less predictive. Conversion to alternative vein conduits can improve the vessel caliber for recipient vessels. The CV is often optimal due to vessel reach but is sometimes absent or injured in this complex population with a high need for central and peripheral venous access.