Preclinical and human tracheal replacement with aortic grafts: a narrative review.

Abstract

Background and objective: Numerous reviews have been published in the field of tracheal replacement. However, most did not differentiate between patch tracheal reconstruction (PTR), non-circumferential tracheal replacement (NCTR), and full-circumferential tracheal replacement (FCTR). This distinction is essential in terms of postoperative mortality. So far, the most widely used tracheal substitutes are the cartilage-reinforced forearm free flap (FFF) and the cryopreserved aortic allograft (CAA), respectively. The aim of our study is to identify and report the results of both preclinical and human use of the aortic grafts in tracheal replacement with a focus on the benefit/risk assessment in clinical practice.

Methods: We performed an in-depth literature search with no language restriction (PubMed/MEDLINE) in order to identify articles related to the topic up to September 2025. Articles focused on experimental and human use of aortic grafts for tracheal replacement, including the authors' experience, were selected for the present review and reported in a narrative fashion.

Key content and findings: In the setting of preclinical studies, we identified 22 articles and one relevant abstract from 1958 to 2025. In the field of human use, we retrieved 20 articles from 1999 to 2025. From a structural viewpoint, our studies of preclinical and human use of aortic grafts implanted into the trachea show that they transform into flaccid tube-shaped scar tissue that contracts over time around the luminal support up to an average of 60%. Occasionally, the graft is subject to endochondral ossification. In the clinical setting, we highlight the usefulness of aortic allograft in the case of tracheal anastomosis dehiscence. In contrast, due to the significant difference between partial and FCTR with a postoperative mortality rate of 0 vs. 18.9%, we have some reservations about the implementation of the latter procedure, mainly in the field of low-grade radiosensitive malignancies such as adenoid cystic carcinomas (ACCs).

Conclusions: Physicians must be aware that the ideal tracheal substitute has not yet been discovered before considering a potential FCTR, mainly in oncology.