Aortopexy for Innominate Artery Compression of the Trachea
Main Text
Table of Contents
Tracheomalacia is a rare congenital condition that results in incompetence of the trachea, the main airway, leading to collapse of the trachea during respiration. Most often this is due to inadequate bone formation in the trachea, and this causes it to be dynamically collapsed, which can result in breathing difficulties for the child. Upper respiratory infections can also be more common. While most cases of tracheomalacia resolve by 18 to 24 months of age, a small percentage either continue or cause such severe breathing or feeding issues that surgical intervention is warranted. In cases where the innominate artery is the cause of compression of the weakened trachea, an aortopexy to elevate the vessel up to the sternum and away from the trachea is performed.
Tracheomalacia; tracheoesophageal fistula; aortopexy; newborn respiratory distress; innominate artery.
Patients with tracheomalacia present primarily with breathing difficulties, the most common of which is wheezing. Many times this occurs in the setting of prior tracheoesophageal fistula repair, with the symptoms beginning only after repair of the fistula. Care should be taken to elicit symptoms consistent with cyanosis or feeding difficulties, as these can indicate a more severe problem than that indicated by the physical examination. Since most cases of tracheomalacia resolve without intervention, it is crucial to take into account the age of the patient and the overall clinical course up to the present when making a decision for surgery.
Findings consistent with airway compromise guide management. Specifically, breathing noises that may change with position and improve during sleep, or that get worse with coughing, crying, or feeding. Look for high-pitched breathing and rattling or noisy breaths. Expiratory stridor at rest, biphasic stridor, and cyanosis are findings that are indicative of severe airway compromise. In addition, care should be taken to rule out gastroesophageal reflux disease and, in patients with prior repair, recurrent tracheoesophageal fistula, as these latter two conditions can cause the same symptoms, or even co-exist with tracheomalacia.
The diagnosis of tracheomalacia is confirmed by laryngoscopy, or direct visualization of the trachea, where a recurrent fistula may also be ruled out in those patients who underwent prior repair. Ancillary studies include CT angiogram of the chest to help document compression due to the innominate artery, as well as a barium swallow to rule out gastroesophageal reflux disease in those children where presence of reflux is suspected.
Most cases of tracheomalacia resolve with time, with the more mature airways proving more resilient to compression due to maturation of the bones of the trachea. However, in patients with severe respiratory compromise due to tracheomalacia, progressive pulmonary illness with severe infection, failure to thrive, and even loss of life may occur.
In this case the child was 38 months old with the symptoms of chronic cough, recurrent respiratory infections, and a history of tracheoesophageal fistula.
Other than supportive care, including treatment of upper respiratory tract infections, medical management for tracheomalacia includes use of ipratropium bromide, bethanechol, and in severe cases, continuous positive airway pressure, or CPAP. Other treatment options include tracheostomy, intubation, bioresorbable stents, and tracheopexy․
The rationale for aortopexy resides in the severity of the condition being treated. In children with severe respiratory compromise due to compression of the trachea by the innominate artery, aortopexy is the only viable treatment option. Only after the child has failed more conservative measures is aortopexy recommended. Previously attempts have been made at endobronchial stenting; however, high complication rate associated with this procedure.
Posterior tracheopexy is a securing of the posterior wall of the trachea to the anterior spine ligament, which helps to stabilize the airway and prevent collapse. Combination with aortopexy can significantly improve breathing and reduce symptoms. This method is effective in patients with severe tracheomalacia associated with conditions like esophageal atresia.
Obstruction of the main bronchus by the innominate artery must be documented to ensure that the appropriate patients are being selected for surgery. Prior cases of tracheoesophageal repair require documentation that the fistula has not recurred.
Tracheomalacia may be subdivided into primary and secondary classifications. Primary tracheomalacia is a congenital absence of the trachea-supporting cartilage normally present, while secondary tracheomalacia is a result of some external insult to the trachea, such as the previously mentioned tracheoesophageal fistula, oesophageal atresia. In addition, vascular rings and an aberrant innominate artery are also causes of secondary tracheomalacia. While classification is helpful in understanding the disease process, a successful aortopexy relies on the diagnosis of an obstructing innominate artery, regardless of the classification.
The first description of the diagnosis and treatment of compression of the trachea due to an anomalous innominate artery was published over sixty years ago.1 Subsequently, tracheomalacia associated with tracheoesophageal fistula2,3 has been added as an etiology of tracheomalacia treatable with aortopexy. The traditional approach to aortopexy has been via a thoracotomy incision, where access to the mediastinum is gained by incising the pleura, done either through the left or right chest. Multiple other approaches have been described in addition to the thoracotomy,5 including thoracoscopic and partial sternotomy, with no approach having a clearly better outcome with respect to the others, although true comparison is difficult due to the rarity of the disease and the procedure.
Due to its high natural resolution rate, breathing difficulties due to tracheomalacia should be treated surgically only in very select patients, after all non-operative options have been explored and/or exhausted. The recovery from the procedure itself is relatively rapid, and other than failure of the surgery to correct the respiratory compromise, long-term complications are few, but tend to be musculoskeletal in nature and more commonly associated with the thoracotomy approach.6
A pediatric chest wall retractor is needed, as well as an infant bronchoscopy set.
The authors have no disclosures.
The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.
Citations
- Gross RE, Neuhauser EBD. Compression of the trachea by an anomalous innominate artery: an operation for its relief. Am J Dis Child. 1948;75(4):570-574. doi:10.1001/archpedi.1948.02030020585007.
- Benjamin B, Cohen D, Glasson M. Tracheomalacia in association with congenital tracheoesophageal fistula. Surgery. 1976;79(5):504-508. https://www.surgjournal.com/article/0039-6060(76)90356-1/abstract.
- Corbally MT, Spitz L, Kiely E, Brereton RJ, Drake DP. Aortopexy for tracheomalacia in oesophageal anomalies. Eur J Pediatr Surg. 1993;3(5):264-266. doi:10.1055/s-2008-1063556.
- DeCou JM, Parsons DS, Gauderer MWL. Thoracoscopic aortopexy for severe tracheomalacia. Pediatr Endosurg Innovative Tech. 2001;5(2):205-208. doi:10.1089/10926410152403174.
- Jennings RW, Hamilton TE, Smithers CJ, Ngerncham M, Feins N, Foker JE. Surgical approaches to aortopexy for severe tracheomalacia. J Pediatr Surg. 2014;49(1):66-70. doi:10.1016/j.jpedsurg.2013.09.036.
- Holcomb GW III, Rothenberg SS, Bax KM, et al. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis. Ann Surg. 2005;242(3):422-430. doi:10.1097/01.sla.0000179649.15576.db.
Cite this article
Scott A, Jackson CCA, Chwals W. Aortopexy for innominate artery compression of the trachea. J Med Insight. 2014;2014(10). doi:10.24296/jomi/10.
Procedure Outline
Table of Contents
- General anesthesia is given via mask induction in the operating room.
- Due to average age of patient and the tenuous nature of the airway, all anesthesia is given in the operating room due to safety considerations.
- The Pediatric Intensive Care Unit should be made aware of patient so they are prepared to receive them postoperatively.
- Patient is placed in left lateral decubitus position at an approximately 30-degree angle.
- All bony prominences are well padded.
- A bronchoscopy is performed before thoracotomy to identify the level of tracheal obstruction.
- A thoracotomy incision made in third right anterior intercostal space.
- Pectoral muscles are incised medially and split towards lateral end of incision.
- Perichondrium and periosteum of rib are incised and separated from the cartilage and bone respectively.
- A chest retractor placed.
- The lung is retracted with a moist wet sponge.
- The thymus is mobilized away from the superior vena cava (on the right), taking care not to injure the phrenic nerve.
- The ipsilateral thymic lobe is resected, exposing the innominate artery and vein and the aorta.
- The ipsilateral pericardium is incised and opened to expose roots of great vessels.
- While bronchoscopy is performed, the aorta is lifted manually in several places to identify the optimal site for placement of the pexy sutures.
- Once optimal site is identified, three pexy sutures are placed through pericardial reflection and aortic adventitia at the base of the innominate artery.
- Care must be taken to NOT place suture through tunica media of the aortic wall.
- Sutures are then placed through posterior periosteum of sternum.
- Under direct bronchoscopy, the innominate artery is elevated and the three pexy sutures are tied down to approximate the innominate artery to the sternum, thus elevating it off of the trachea.
- The wound is closed in layers, with specific attention paid to the fascia of the pectoralis major to ensure no problems with muscle strength long term.
- Subcutaneous tissues are closed using a 3-0 Vicryl suture.
- Skin is reapproximated using a 5-0 absorbable monofilament suture such as Monocryl.
- Normally a chest drain is not needed if the operative field is dry.
- The patient is encouraged to feed orally after surgery and is kept in the Pediatric Intensive Care Unit for postoperative observation.
- If the patient feeds well and the respiratory symptoms improve, the patient may be discharged the next day.
Transcription
CHAPTER 1
I’m Walter Chwals, the Chief of Pediatric Surgery at the Floating Hospital for Children in Boston, Massachusetts. I’m here to discuss today an aortopexy. The procedure is usually done in a child who has tracheomalacia. Tracheomalacia is usually associated with other anatomical variations that are congenital in nature. For instance, tracheoesophageal fistula often results in tracheomalacia. The cartilage of the trachea is poorly developed, and during expiration, when intrathoracic pressure increases, the trachea collapses as a result of the improperly formed cartilaginous tissue. This can lead to feeding difficulties in children who have tracheomalacia or - in more serious circumstances - can lead to cyanosis and even airway collapse with respiratory embarrassment requiring intubation and resuscitation. So it's not a trivial issue in many clinical situations in which it exists. In understanding the way that an aortopexy works, it is important to understand the anatomy of the aortic arch as it is associated with the trachea itself. The trachea lies behind the aorta - aortic arch, and the rationale behind doing the aortopexy is to elevate the aortic arch by attaching it to the underside of the sternum and in so doing elevate the trachea along with the aortic arch, which is being elevated. So when one elevates the arch, one pulls the trachea behind the arch up along with the arch itself.
CHAPTER 2
The procedure begins with flexible fiber optic bronchoscopy, which is performed through a laryngeal mask ariway. Here we’re at the level of the carina, and as we move more proximally, this site of the prior tracheoesophageal fistula, which has been closed, can be seen. More anteriorly, we reach the height of the aortic arch and the innominate artery, which is causing compression. Tracheomalacia can be seen here posteriorly. The cervical trachea demonstrates normal caliber, and as we move more proximately into the subglottis, this airway is clear. The vocal folds appear normal.
CHAPTER 3
Just biases the lower part of the incision, right over here. Incision is made in the anterior aspect of the chest wall, overlying even - the third cartilaginous rib or the fourth cartilaginous rib. Can we go fifteen-fifteen? I prefer the right side. Many prefer the left side instead. It’s a matter of individual surgical preference. In either case, the thymus, which overlies the aortic arch, should be least partially removed. And this is to create a space between the aorta and the underlying sternum. We knew about where this was because of imaging that we'd gotten both from the endoscopy as well as some plain films. So I think that the important concepts of this are first to gain adequate exposure. Second - to remove a portion of the thymus to create the space. Though it’s a mistake not to remove some of his thymus. The problem with that is the thymus may get squeezed in between the aorta and suture, weakening the aorta and the sternum - weakening the suture line - or you don’t get adequate elevation. Alright so, we’re still in the mediastinum now. Now we’re going to get the thymus and a portion of that thymus and do a lateral thymectomy - a right lateral thymectomy. We’re gonna go up on the underside of the sternum now and free that. Just going by feel there? Yeah. I’ll stick my finger in it eventually. Do you have a rib spreader now, please? So you can see the medial margin of the right lung and the intact pleura. The approach to the mediastinum involves blunt dissection of the right or left parietal pleura away from the field without entering the pleural cavity, so a chest tube is not needed. And generally speaking, drains in the mediastinum are not needed either. There’s the thymus. Okay. Just want to get the pleura to go back as much as as possible. And then we’ll take the thymus out. You can now see the lateral border of the thymus coming into view. I hope I won’t tear the pleura. That’s thymus. Yeah, you just want to make sure the lung and the pleura are intact. This is where you can easily tear into the... Yes. You can now see this - the thymus coming into view pretty nicely. You just want to remove that thymus to create the space between the aorta and the posterior margin of the sternum. Sternum. So you have something to sew to. Now there’s a... Do we have those silicone-guarded retractors? The malleables? So the inferior thymic vein that comes up here, and then there is an arterial branch off the internal mammary. Probably not, let me just - this is just counter traction - traction, counter traction - kind of trying to develop, but these kids have big thymuses. Yes, particularly at this age. Sort of posterior aspect in the thymus down there. You can see that now. We're developing that up now. We're get - we’ve gotten to the lateral border. And there’s a little vein coming in there. Well that is the phrenic nerve. Where do you see that nerve? Right there, overlying the - oh there, I see it. Yeah, great. I was seeing the vein coming up lateral to medial. So there’s the phrenic. There’s the phrenic nerve, and now we’re on the SVC. And you want to not get into the pleura if you can - you know, into the pleural cavity if you can avoid that. You can do a lot of this with just blunt dissection. Yep. Careful blunt dissection. I’m just going to stay on the superior vena cava here. Okay. You just use that as your margin. Let me have the Metzenbaum scissors. And usually once you get this started with a little incision, you can sort of chase it down. Yep. But you just keep working down and down and down on the thymus until you get the inferior margin up in your face. And here, you know, the parietal pleura is still trying to sneak into your - I mean, it's almost like it wants to get cut. And it’s not the end of the world if you happen to get into the pleura by the way, but stay outside his spine. I always use the Sangly’s for this just cuz they're less traumatic. Alright, now we're at the medial side of the superior vena cava. Try not to molest the phrenic nerve as much as possible. We’re sort of lifting up and off the - we’re lifting the thymus up and off of this area, trying to get behind it a little bit. So sometimes I'll just take out a portion of the thymus and then go back and take out more if I need - need to. There we go. We finally got the inferior part free. Yeah. Now just Bovie that. Stay on your upper jaw. Go right between them. We don't remove the rib, but you can - you can - if you have difficulty in achieving exposure, you can remove the cartilaginous portion of the rib and allow for greater expansion of the tissue within the wound space, and then we leave the pericostal rib intact for the new cartilage. It really does mobilize quite nicely once you get it up. Just have to be patient. Sangly. please. I’ll take this right about here. Go ahead. Bovie. That’s just the - right side of the - left side of thymus there. It might be the left lobe. Yeah, it's just.. As long as we can push that back and create enough space here, we’re all set. There we go. Can I have a right angle now, please? Thank you. Creating enough space for elevation of the aorta - that is the purpose behind removing about 50% or so of the thymus because that allows for the space for proper elevation of the aorta. These children have huge thymuses. Right on the front there. Right here, yep. Right on the prong. Okay. Alright, let’s see a Schnidt. Alright, let’s have the ligature now. Yep. Show me the underside of this. Alright, let’s try that again. Okay so, that’s the right thymus - so there’s SVC. Lobe. Right in front of us. And now, see if we can expose the aorta a little better. The aorta is right there. Take out the Schnidt. Can I get another retractor under there? We’ll have to take out a little more of this... So here's - here's the innominate vein right there. And we're gonna have to get up into this area. Right over here is the innominate vein. A little lymph node. So I will chase a little more of this thymus now. There’s plenty of thymus left, so let’s get a little more of this out. And that's what I mean by - you know, you take out the thymus that's in your face, and you can see much more about what you need to do next. Yeah. There's the pericardial reflection. Right up - right there. I don’t know if you can see it. Right there. Yes. Yes. So, take off a little bit more of this. And again, same thing - we try to move the thymus up off of the aorta from inferiorly to superiorly to try to get that inferior margin. You can see, as we continue to do this, more and more - more of the lobe emerges. Yep. And I think this is about all that I really need to take is this area. Cuz the rest retracts enough away from the...? Right. Okay, that’s perfect. LigaSure back. So that’s still some more. Yeah. That's the last part. More thymus. Okay. Here is the aorta and aortic trunk. And here is the superior vena cava. Here is the branch of the superior vena cava and the innominate vein. The innominate vein is right here. Superior vena cava is right there. This is the - we’re retracting back the lung, and this is the - the phrenic nerve right there, intact. Okay. We’ve removed a substantial portion of the thymus on the right side, and at the base of the aorta here, you see the reflection of the pericardium coming up onto the aortic bace right there. We’re about to open that in a transverse fashion right over here. Okay so here, as you see, we’re opening to the pericardium. See that? Yes. Right there. See the pericardial fluid coming right out. Suction? Thank you. Now I’m just going to open this up a little bit on either side. Alright, that’s exposed. So that’s our aortic root? Yeah, exposed pretty well. Alright, so... I see how we couldn’t really do that with that intact because you wouldn’t be sure you have the... Right. You want to get - have Andrew come in, and what we'll do is lift up the aorta and see whether or not... Can we get Dr. Scott? Get a better sense of where… Okay so now, we are exposing... Oh, there we go - nice. See the base there There’s our innominate. Yeah, so I think we’re where we need to be for all this. Very nice. You have the stitches ready? Now we’ll take - let’s see how I want to do this now.
CHAPTER 4
Okay, gentlemen. Let me know when you're in there. You got it. Alright, well why don’t you go and pull up a little bit and see if you can get any. Alright. How about right there? Yeah, that’s impressive. That says a lot. Okay, is that better than... Give me like a number one and a number two. Okay, here’s number one. There’s number one. Here’s number two. Both of those are equally efficacious. And... You’re going to need to go more superior... Wait a second. And here’s number three. Yeah, number three is the money. Okay, and that's right on the brachiocephalic trunk. Okay, that helps us. Alright, let’s have a stitch.
CHAPTER 5
Pediatric otolaryngologists are very helpful in visualizing the trachea in the collapsed and the expanded state to see that the expansion, which we've achieved through placement of these sutures, is adequate. The sutures are placed using 4-0 Prolene. You can also use 4-0 silk if you prefer, but the Prolene is less reactive for the vascular wall, especially. And we pledget those Prolene sutures to try to avoid further trauma to the aorta. Okay, table up. Turn the table away from me. Not anymore, yeah. Can I give you that back, Janice? More. That's good. Make sure that the interrupted mattress sutures - I put in two rows of those - are adequately placed over a broad enough area to elevate the aorta. A better thing even would be to sort of move the aorta up against here, so you can get more surface area involved. Hold that, James - just get it taut, yeah. Total of six horizontal mattress sutures we place in this particular case. These suture should not be taken full thickness and are instead taken through the adventitia and the media of the aortic wall, bearing the intima. The sutures can be interrupted or equally spaced. I usually take them in two rows - three sets of sutures up through the anterior aorta to the branching of the brachiocephalic artery from the aortic arch. Let’s see. Now, let me have that for a second. You have to feel yourself going into the cartilage on that. Another stitch. Okay, now to use the pledget ones. Down farther, please. Table down farther. If you have the needle driver, you can try to bend it? Yeah. What - what size needle is this? BB. Alright, let me have the vein retractor again? That works. Wait, wait. Let me just see if I... Have a Kittner ready as well. Yep, all set. Turn the vein retractor just like that. That may work. We’re almost finished here. Can I have a rubber shod? Can I have the other needle driver, please? Okay, here let me take that. So you all - so - so what do you guys use? Prolene or something? Okay. Yeah, 4-0 Prolene. Table down, please. Sure, coming down. And you get a good as hunk of periosteum basically? Yeah. The trick is getting the needle in and out at the right angle. Right. And the same thing - suction. So you're not too tangential. Right. Do you - do you overbend it? Yeah. Sort of have to bump off the periosteum instead of skiving? That’s it. Alright, now another vein retractor - yeah. Vein retractor, please. As you lift the aorta anteriorly, you lift the trachea with it, and the posterior aspect of the trachea is still also attached to surrounding tissue against the anterior surface of the thoracic vertebra so that, when you lift the aorta up and it pulls the trachea up with it, it also expands the trachea because the posterior aspect of the trachea, which is attached to the vertebral bodies, where the soft tissue associated with the vertebral bodies stays in place. So in effect, you are expanding the tracheal lumen by lifting the aorta. Okay now, I will take a pledget. And let’s see, there’s another needle up here somewhere. It's right here. And we’ll put in one more stitch, and then we’ll have Andrew go in and... Watch while we tie. Yeah. Well, first we'll pull up. Alright, let’s have the shod - shod, shod, shod. Okay, one more stitch. Needle driver. You have good this is the last - exposure? This is the last - yep. Good exposure. So we got the last stitch going in. Postoperative complications include not only bleeding from sutures, which erode through the aorta, or sutures which have been inadvertently placed into the aortic lumen and erode through but also infection and finally recurrence. And recurrence is more frequently associated with sutures which are inadequately placed. Ultimately the sutures which we place are only as strong as the tissue we put the sutures in, so it's important to get good tissue bites on the periosteum of the posterior sternum and adequate tissue bites into the adventitia and medial aspects of the aortic wall. And again, pledget reinforcement of these sutures will help to avoid erosion of the suture through the aortic wall, but it is important to get adequate tension and purchase of the aortic wall over a broad enough area so that the trachea is adequately expanded. Okay let’s have the needle driver and the pledges. Okay. Thanks. Alright, Andrew, are you ready to go back in? You ready? Okay. Yeah. Push the trachea. See how flexible it is? Because it's so... Yeah. Okay. So give us the word when you want us to pull. Alright, give - give a pull. Wow a lot of resistance now. Yeah, I'm sure. It won’t be long - much longer. Alright. Okay, now relax. Okay, now pull again. You can see how it passively opens your fistula too. Now relax. Good. And you feel good about all those sites? Yeah. It looks great. Alright, I’m a gonna... Gonna tie them away? Yeah, I’m gonna tie them. Yeah. Great. Alright, so... Go ahead and ventilate, Paul. Just cut one - here this one. Okay. Okay, here’s your needle back. You got it? I do. Alright. A little wet. Alright. Sure. Don’t you love a little positive feedback? Doesn't that just... I know, yeah. That's like me rubbing your back, basically. It's true. In a very like collegial, non - non-threatening kind of way. Professional way. That’s an attaboy. That’s a surgical attaboy. Alright. When you’re tying, do you try to get it totally up to the sternum. Okay. Yes, I do - yes, I do. Alright, let’s have scissors. Do you have Metz for the next time? Here's your other needle back. Sure. You got it? Okay. Yep. Okay, so we can just cut that one off, right there. That's a really nice stitch. You can see it beautifully incorporated. Great. After we’re done, I’ll get you to look in there with a camera to show everything. Well I think the camera is going right now, I mean... Yeah, but dropping your head to kind of look under to the side. Alright, scissors, please. Metz. Here’s your needle back. See I think, normally, you would put one down here too, but... Okay. I don't think we need to because this is high. And that's why we had to go up here in an area we don't normally have to go. Here, let’s cut this... Give me a needle. Can you cut that off? You got it? Yep. And the key with this - cuz you’re using 4-0 - is not to break the suture. Yes. It’s not the knot. It’s the jerk at the end. Yeah. You can cut this off too. Here’s your other needle. So, table up, please. Sure, coming up. Alright, that's enough, thanks. So let me have a right angle retractor, please. And a DeBakey. Now, what would be nice at some point - if you guys are up for it - would be to... We might need to angle this camera a little bit... Right, to get an LMA in there. So right here is the stitches. Attaching the aorta to the sternum. And here’s the lung. Pull it up a little - tilt you head up just a bit. Alright. Focus up here because your camera's angled. That’s great. Alright so we see the sutures in place with the pledgets in place - the lung and the parietal pleura coming up into the wound here. I don’t see a lot of air in there. I think we're gonna just leave it alone. Yeah, as far as our tube? Yeah. Yeah, there’s very little - there’s a little bit of a tear, but I think it looks like it’s managing well. Alright, good. Good. Let’s take the table down now, please.
CHAPTER 6
So are you gonna try to get a pericostal or not even bother? Yeah, I’m not going to bother because - I don’t know. Let me see about this. I don’t know if we can get it easily. It’s a pericostal on the... Paul, do you want to see your - your handiwork? Okay, yep. Wow! Okay. That - that's good. Is he on positive pressure? Or a peak? Yeah, take off some of your peak. Oh, that’s good. That’s good. You can see the fistula there too. That’s great. Alright, excellent. Alright. Yeah, so the pericostal kind of go on repair too. See, this is costochondral. This is the - this is the chondral portion. That’s not - you don’t - I wouldn’t put a... Around the rim. Yeah - a pericostal on that. What you’ll just do is get the fascia of the pectoralis and close that. You guys got that last bit? Great. Alright well, that’s great Andrew. That's good - good pictures. Nothing you can get above that, right? There's no - no sense going higher on the innominate? No, that - the problem with that is... Because you’d have nothing to sew it with. No, it's the fact that you would then crimp the innominate vein, which is lying right over the top. You want to do this? Yeah, I can do that. So the next one... You do it, and I'll assist you. Yeah, that sounds good. I - this - this way I can even see this one. You needed to just get it. It was not easy. Well, you know, once you see them, yeah. I’d never seen one before, so I needed to know what to do. I appreciate you coming up. It was a pleasure. Thank you. This worked out well. So tell Jeremy. Oh yeah. At the end of the case, after they do their nerve block, we're going to put an LMA in again and get an identical shot to your pre-op. I think that’ll be nice bookends.