Feasibility and outcomes of long-segment tracheal replacement with biological and engineered scaffolds.

OBJECTIVES

To synthesize adult long-segment tracheal replacement using a combined anatomical and graft-based framework and to compare clinically established and investigational strategies with emphasis on mortality, morbidity, airway function, and reintervention.

METHODS

PubMed/MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library, and China National Knowledge Infrastructure were searched from January 1, 2000, to June 30, 2026. Adult replacements were classified as Type I (upper/cervical), Type II (cervico-mediastinal), Type III (intrathoracic), or Type IV (distal trachea/carina) and by graft class. Forty-three reports comprising 147 extractable patients were synthesized descriptively. The overlapping 50-patient TRITON-01 registry was analyzed separately as the principal cryopreserved aortic-allograft benchmark.

RESULTS

Among 147 patients, 72 were Type I, 33 Type II, 25 Type III, and 17 Type IV; 113 (76.9%) had malignant disease. Autologous vascularized tissue composites were used in 74 patients (50.3%) and cryopreserved aortic allografts in 52 (35.4%). Overall 30-day and 90-day mortality were 4.8% and 9.5%, respectively. Decannulation was achieved in 103/139 (74.1%); 25.2% required repeat endoscopic intervention and 19.0% developed recurrent stenosis. In the updated 50-patient TRITON-01 registry, 30-day mortality was 4%, major complications 30%, stent-related granuloma 52%, and stent removal 30%. Reliable Type I-IV-specific mortality rates could not be pooled because primary reports did not consistently cross-tabulate outcomes by anatomical level.

CONCLUSIONS

Anatomy should precede material choice when interpreting tracheal replacement. Autologous vascularized composites have the most mature experience for selected Type I-II reconstruction, whereas Type III-IV intrathoracic and distal/carinal replacement remains more technically hazardous. Cryopreserved aortic allografts provide the current clinical benchmark for biologic full-circumference replacement but require structured stent and bronchoscopic management. Tracheal allotransplantation and engineered or xenogenic constructs remain limited or investigational.