Imaging strategies for vascular rings

Long-Term Outcome of Surgically Repaired and Non-repaired Double Aortic Arch in Children

Introduction A double aortic arch (DAA) is a rare congenital vascular anomaly that encircles the trachea and esophagus, resulting in compression of both structures and causing variable symptoms of wheezing, stridor, increased work of breathing, or dysphagia. DAA usually presents in infancy but can be incidentally found later in life. The standard management of DAA is surgical repair. However, observation and follow-up have been recommended in asymptomatic or mild cases. The long-term outcome of surgical repair versus observation is not well-reported. We described the long-term clinical outcome of patients with DAA who were surgically repaired versus non-repaired at our institution.  Methods Electronic medical records were searched for the patients diagnosed with DAA before the age of 18 years. Data from clinical, radiological, and bronchoscopic findings, pulmonary function test (PFT), and cardiopulmonary exercise testing (CPET) were extracted. A structured phone questionnaire of patients' parents regarding past and current symptoms was also conducted. Results A total of 12 patients (eight males four females) with DAA were identified. Median age was 8.5 (1.5-17) years. The age at diagnosis was 60 (1-192) months. Post diagnosis follow-up period was 20 (2-156) months. Five patients were surgically repaired, and seven patients were not repaired. The median age of surgery was five (1-15) years in repaired patients. The phone questionnaire was completed in only 10 patients (five repaired and five non-repaired). Respiratory symptoms in infancy were reported in all repaired and non-repaired patients and were resolved in all five repaired patients and in four of the five non-repaired patients. One non-repaired patient complained of intermittent dyspnea on exertion. Gastrointestinal symptoms were present in infancy in three repaired and three non-repaired patients and were improved in two repaired and one non-repaired patient. PFT was performed in five patients (one repaired, four non-repaired) and showed normal forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC in all patients. Low peak expiratory flow (PEF) was seen in the repaired patient and in three of the non-repaired patients. CPET was conducted in four non-repaired patients and showed maximal oxygen consumption (VO2-max) of 66% predicted (58-88), maximal ventilation (VE-max) of 75% predicted (70-104), and ventilatory reserve of 55% predicted (48-104).  Conclusion Long-term clinical outcome is favorable in both repaired and non-repaired patients with DAA even though both groups reported respiratory symptoms during infancy. Therefore, clinical observation is a legitimate option in certain DAA patients.

Balanced double aortic arch demonstrated by multimodality image and 7-year follow-up in a symptomatic elderly patient: A case report

Double aortic arch is a very rare congenital heart disease. Double aortic arch forms a vascular ring, compressing the esophagus and trachea, causing symptoms mainly in infants and young children, and symptoms rarely appear after adulthood. The management of double aortic arch depends on the severity of the symptoms, but since aging exacerbates atherosclerosis and complicates surgery, treatment in adults has many considerations. A 55-year-old woman admitted for chest discomfort, mild dyspnea and mild dysphagia. On a simple chest X-ray, dilated upper mediastinum and bilateral aortic knobs were noted. Transthoracic echocardiography revealed 2 aortic arches on suprasternal view. Contrast-enhanced computed tomography and 3-dimensional computed tomography demonstrated a balanced double aortic arch which formed a complete vascular ring and compressed the esophagus. Barium esophagogram showed marked luminal narrowing at the aortic arch level, probably due to indentation of the double aortic arch. She had several risk factors regarding progression of aortic atherosclerosis include old age, hypertension and dyslipidemia that make more severe compression of esophagus and trachea, but the symptoms were not severe, so we decided to observation while controlling the risk factors. For the next 7 years, she stayed without worsening of symptoms.

Rings and Slings: Not Such Simple Things

PURPOSE OF REVIEW

Vascular rings are congenital malformations resulting from abnormal development of the great vessels, with the consequent encircling and compression of the trachea, esophagus, or both. We conducted a review of the current literature to identify the different management strategies that can be implemented based on the prognosis of each of these anomalies.

RECENT FINDINGS

Although most vascular rings occur in isolation, they can also be associated with other congenital cardiac and/or respiratory diseases; therefore, thorough investigation is necessary before definitive surgical repair. Clinical presentation varies from asymptomatic to severe, with both respiratory and digestive symptoms. Although early surgical results are acceptable, the long-term outcome is variable; therefore, there is still controversy regarding the appropriate timing of treatment. This is especially true with regard to the Kommerell diverticulum (KD) and in patients without symptoms at the time of initial surgical evaluation. As more sophisticated diagnostic tools have become available and more studies on adults affected by this condition have been published, understanding of this condition and its additional clinical implications has grown and appears to be tilting management toward earlier intervention.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Truncus Bicaroticus With Arteria Lusoria: A Rare Combination of Aortic Root Anatomy Complicating Cardiac Catheterization

While most patients with arteria lusoria and common carotid trunk conditions are asymptomatic, discovery of such anomalies periprocedurally may affect the cardiac catheterization access site, catheter selection, and additional imaging.

Successful Surgical Therapy of a Double Aortic Arch in a 10-Month-Old Mixed Breed Dog

A 10-month-old female spayed mixed breed dog with a suspected vascular ring anomaly was presented for exercise intolerance and wheezing. Computed tomography (CT) revealed a double aortic arch. The smaller right aortic arch was successfully ligated via right 4th intercostal thoracotomy. The patient was discharged one day postoperatively and continued to have good outcome at recheck 3.5 weeks after surgery. This is the 4th documented case of double aortic arch with a successful outcome. Preoperative CT scan was vital in preoperative planning and should be strongly recommended in all cases of suspected vascular ring anomalies with atypical presentation.

An incomplete vascular ring causing respiratory distress

Kommerell’s diverticulum is a rare saccular aneurysmal dilation of the descending aorta. We report a case of a 3.5-year-old boy with the extremely rare combination of Kommerell’s diverticulum with a right descending aorta and proximal patent ductus arteriosus aneurysm forming an incomplete vascular ring. To our knowledge, this rare case has not been reported to date.

Right aortic arch with isolation of the left subclavian artery: a rare association with airway obstruction

We present two interesting cases of isolated left subclavian artery from the pulmonary artery with symptoms of upper airway obstruction. The first patient had tetralogy of Fallot, pulmonary artery sling, bilateral superior caval veins, and left bronchial isomerism, suggesting heterotaxy syndrome. The second patient had a right aortic arch, isolated left subclavian artery, and bilateral arterial ducts. These two cases are interesting because of their rarity and uncommon presentation.

Vascular rings: a radiological review of anatomical variations

BACKGROUND

The imaging modalities used to diagnose vascular rings have evolved over time, from basic radiographic studies to advanced cross-sectional imaging. The goal of preoperative imaging is to provide the surgeon with an accurate representation of the ring configuration so that the surgical approach may be planned.

METHODS

We conducted a review of all patients with vascular rings who underwent surgery at Inkosi Albert Luthuli Central Hospital, Durban, South Africa from 1 July 2008 to 1 July 2013.

RESULTS

Eight patients were diagnosed with vascular rings. Seven patients had an abnormal plain chest radiograph (right aortic arch, tracheal narrowing, or abnormal mediastinal silhouette), while in six patients the contrast oesophagogram demonstrated a fixed extrinsic oesophageal indentation. Computed tomography angiography confirmed the pathology in all cases, with six double aortic arches and two right aortic arches with aberrant left subclavian artery and left ligamentum arteriosum.

CONCLUSIONS

We advocate a diagnostic imaging algorithm consisting of plain chest radiography, contrast oesophagogram and computed tomography angiography prior to surgery. Magnetic resonance imaging may provide an alternative axial imaging modality depending on institutional preference.

Rings and slings revisited

Vascular rings and pulmonary artery slings are rare congenital anomalies that often present with symptoms of tracheal and esophageal compression. These can involve the aortic arch branches and pulmonary arteries, respectively. This review illustrates the current role of MR imaging, highlights its advantages, and provides insight into the diagnosis of these anomalies by describing the embryology and characteristic imaging features of these lesions.

Vascular rings: presentation, imaging strategies, treatment, and outcome

This study aimed to evaluate the presenting symptoms, the effectiveness of imaging methods, and the surgical treatment of vascular rings. Data for 44 patients (32 enrolled prospectively, 12 reviewed retrospectively) over a 10-year period in a tertiary referral center were analyzed. These patients comprised 25 patients with a left aortic arch and an aberrant right subclavian artery, 13 patients with a right aortic arch and a left subclavian artery originating from Kommerell’s diverticulum, 1 patient with a right aortic arch and an aberrant left subclavian artery, 3 patients with a double aortic arch, and 2 patients with a pulmonary sling. Respiratory symptoms were found in 25 patients and dysphagia in 6 patients. Atypical symptoms such as reflex apnea, cyanosis, syncope episodes, and exercise-induced wheezing were noted in five patients. Associated congenital heart defects were detected in 41% of the patients. The diagnostic yield was 95.23% for barium esophagography, 54.54% for echocardiography, and 66.66% for computed tomography. The anatomy could be correctly identified by magnetic resonance imaging (MRI) in 97.43% and by angiography in 90.5% of the patients. Of the 30 patients who underwent surgery, 80% were completely relieved of symptoms during a mean follow-up period of 25 ± 33.5 months. Vascular rings should not be overlooked in infants with atypical symptoms. The authors’ diagnostic procedure of choice is MRI because it is superior to angiography for delineating the relationship between abnormal vascular structures, trachea, and esophagus.

A case of balanced type double aortic arch diagnosed incidentally by transthoracic echocardiography in an asymptomatic adult patient

A 36-year-old male patient with no remarkable medical history was admitted to our hospital for a health check up. On chest radiography, bilateral aortic notches at the level of aortic arch were shown suggesting aortic arch anomaly without any clinical symptoms. Two aortic arches were almost same-in-size on suprasternal view of transthoracic echocardiography. In addition, multidetector computed tomography showed balanced type double aortic arch forming a complete vascular ring which encircled the trachea and esophagus. The trachea was slightly compressed by the vascular ring whereas the esophagus was intact. Nevertheless, the pulmonary function test was normal. The patient was discharged from hospital with instructions for periodic follow-up.

Airway obstruction by extrinsic tracheal compression during spinal surgery under prone position -A case report-

Tracheal compression by vascular anomalies in adults is uncommon and most related reports are of children. A 79-year-old woman without any respiratory history underwent a lumbar spine surgery under general anesthesia. She suddenly developed airway obstruction after a position change from supine to prone. A fiberoptic bronchoscopy showed the obstruction of endotracheal tube. The obstruction was relieved after we changed the depth of endotracheal tube and supported the patient's neck with a cotton roll. The surgery ended without any other event and the patient recovered safely. A computed tomography revealed the rightward tracheal deviation and tortuous innominate artery contact with trachea. The patient didn't manifest any respiratory related symptoms during postoperative period, and she was discharged without any treatment.

Adult presentation with vascular ring due to double aortic arch

This is a case report on the use of cardiovascular magnetic resonance imaging to diagnose vascular ring due to double aortic arch in an adult presenting with an abnormal chest X-ray. The experience in this case and the literature review identify the benefits of using cardiovascular magnetic resonance imaging to clarify complex aortic arch anatomy.

Double aortic arch and d-transposition of the great arteries

We present a rare case of D-transposition of the great arteries (D-TGA) and double aortic arch (DAA). The anatomy was prospectively and preoperatively diagnosed by echocardiography and confirmed by ultra-fast computed tomography. The patient underwent successful arterial switch operation and division of the vascular ring at a single procedure.

Endobronchial ultrasound for detection of tracheomalacia from chronic compression by vascular ring

A 67-year-old female chronic smoker was evaluated for an asymptomatic right paratracheal mass and the diagnosis of double-arch aorta was made. She returned 2 years later with dyspnoea on exertion, productive cough and wheeze on lying supine. Flow volume curve showed variable intrathoracic airway obstruction, and bronchoscopy revealed extrinsic compression of the trachea by double-arch aorta with destruction of the cartilaginous layer visualized on endobronchial ultrasonography. Endobronchial ultrasonography may be a useful adjunctive tool for the identification of adults at risk of postoperative tracheomalacia where tracheopexy or airway stenting can be performed concurrently or sequentially if surgery is contemplated.

Management and outcomes of double aortic arch in 81 patients

OBJECTIVES

Double aortic arch is a common form of complete vascular ring, encircling both the trachea and esophagus, resulting in noncardiac morbidity. We sought to describe management and outcomes in a large single institution clinical series.

PATIENTS AND METHODS

We reviewed the medical charts of all of the patients diagnosed with double aortic arch at age <18 years. Data regarding clinical presentation, anatomy, management, and outcomes were abstracted.

RESULTS

We identified 81 patients (67% males) born between 1964 and 2005 and presenting at a median age of 5 months (range: birth to 10.3 years). Respiratory symptoms were present in 91%, including stridor in 77%. Gastrointestinal symptoms were present in 40%, with choking with feeds being most common. The dominant branch of the double aortic arch was right in 72%. Associated cardiac anomalies were present in 18%, with noncardiac anomalies in 7%. Repair was performed in 79 patients at a median age of 6 months. There were 2 deaths after surgical repair with no late deaths, with Kaplan-Meier survival estimates of 96% at 5 years. Postoperative complications included chylothorax in 9%. Only 1 patient required reoperation. The most common symptoms at most recent follow-up were respiratory (54%) followed by gastrointestinal symptoms (6%). Postoperative tracheal stenosis was documented in 14%, with tracheomalacia in 7%. There were no late reoperations and no evidence of aortic arch obstruction.

CONCLUSIONS

Outcomes are excellent after repair of double aortic arch, although persistent respiratory symptoms are frequent and probably associated with previous compression-related maldevelopment of the trachea and major airways.

Three-dimensional CT scanning: a new diagnostic modality in congenital heart disease

New generation multislice CT technology has changed the approach to non-invasive assessment of congenital heart disease, in both paediatric and adult patients. This is mainly because of rapid advances in spatial and temporal resolution and in post-processing capability. At Hôpital Necker-Enfants Malades, CT with multiplanar and three-dimensional reconstruction has become a routine examination in the evaluation of congenital heart disease planning surgery, complex interventional catheterisations and for follow-up. It has proved to be an invaluable diagnostic and decision-aiding methodology in these situations, as a complement to echocardiography and, increasingly, as a substitute for diagnostic angiography (which is usually associated with higher-dose radiation and longer sedation times, as well as occasional morbidity). This review illustrates the current status of 64-slice CT in congenital heart diseases, including assessment of the aorta, the coronary arteries, the pulmonary arteries, the systemic and pulmonary veins, and other intra- and extracardiac malformations.

Right aortic arch and coarctation: a rare association

OBJECTIVES

Understand anatomical and clinical correlatives to coarctation in right aortic arch.

BACKGROUND

Coarctation of the aorta is rare in patients with a functional right aortic arch. We reviewed a single institutional experience, examining associated diagnoses, diagnostic methodology, and surgical approaches.

METHODS

A retrospective study was performed of our echocardiographic, magnetic resonance imaging, catheterization, and surgical databases from 1988 to 2001.

RESULTS

Of 240 patients with right aortic arch, 10 (4.1%) had coarctation, constituting 1.9% of all native coarctations (n = 524). Nine (90%) had long-segment hypoplasia. Six (60%) had an aberrant left subclavian artery or retroesophageal diverticulum, 3 (30%) had mirror image branching, and 1 (10%) had a double arch with an atretic left arch. Other congenital heart defects were seen in 6 (60%) comprising 3 with ventricular septal defects, and one each with double-outlet right ventricle, cor triatriatum, and pulmonary valve abnormality. No patients with long-segment hypoplasia had bicuspid aortic valve. Six (60%) had vascular rings, and 5 (50%) had other associated syndromes. Magnetic resonance imaging and/or echocardiography successfully diagnosed all of these patients. Although long-segment right aortic arch coarctation courses behind the trachea posteriorly, only 2 needed an extra-anatomic (jump) graft; the remainders were repaired with patch angioplasty.

CONCLUSION

Coarctation with right aortic arch is rare, constituting 4.1% of all patients with right aortic arch, compared with 5-8% of patients with left aortic arch and congenital heart disease. Nearly all had long-segment hypoplasia without bicuspid aortic valve, and half were part of other syndrome complexes. This association can be diagnosed noninvasively and can often be repaired by patch angioplasty.

Adult dysphagia associated with type B double aortic arch

Esophageal compression secondary to a double aortic arch is rare in adults due to its propensity to cause severe symptoms in infancy or childhood. We report four adult patients with dysphagia associated with a double aortic arch. Chromosome analysis in one of these patients revealed a balanced translocation between chromosomes 4 and 18 - this has not been previously reported. Surgical division is indicated in all symptomatic patients and provides excellent operative results.

Magnetic resonance imaging of a distorted left subclavian artery course: an important clue to an unusual type of double aortic arch

The objective of this study was to determine if distortion of the left subclavian artery course distinguishes double aortic arch with atretic left dorsal aorta from right aortic arch with mirror image branching. We performed a retrospective case series at a tertiary care center. Twenty-six patients undergoing magnetic resonance imaging for suspicion of a vascular ring were identified, 6 of whom had an atretic left dorsal aorta confirmed by surgical inspection. Six patients with the diagnosis of right aortic arch with mirror image branching were identified for comparison. The course of the left subclavian artery was assessed using surface-rendered magnetic resonance angiography (MRA) and axial fast spin echo images. All patients with double aortic arch had clinical symptoms suggestive of esophageal or tracheal compression. Six patients had double aortic arch, 3 of whom had an atretic left dorsal aorta. In these 3 patients, the branching patterns on MRA mimicked right aortic arch mirror image branching except for the distortion of the initial course of the left subclavian artery. Surgical observation confirmed the presence of an atretic left dorsal aorta that resulted in tension on the left subclavian artery pulling it posteriorly and inferiorly and completing the vascular ring. Patients with right aortic arch mirror image branching demonstrated no such subclavian artery distortion, and these patients did not have clinical symptoms suggestive of a vascular ring. Our results demonstrate that left subclavian artery distortion due to traction by an atretic left arch is an important diagnostic finding in the evaluation 6 patients with suspected vascular rings.

Impact of preoperative diagnosis of congenital heart disease on the treatment of esophageal atresia

Congenital heart disease (CHD) has a major impact on the survival of babies with esophageal atresia (EA). The present study assesses whether early diagnosis influences the management strategies in a large series of EA. Cases of EA treated between 1982 and 2002 were retrospectively divided into groups according to the presence or absence of CHD and to whether this was diagnosed or not prior to tracheo-esophageal fistula repair. Patients were also staged according to Spitz's classification in which major congenital heart disease (MCHD) are those associated with cyanosis and/or heart failure requiring surgery. Comparisons between groups of patients were made by standard statistical tests. Among 195 babies with EA (99 boys and 96 girls), 82 (42%) had CHD (31 boys, 39% and 51 girls, 61%, chi2 P < 0.05) and 43 out of these 82 (52%) had MCHD. Six children died without treatment. CHD was diagnosed prenatally in six cases and before EA repair in 26 cases. The diagnoses were missed in 12 instances (in five it was a MCHD). Regardless of preoperative diagnosis of right aortic arch in 3/6 cases, the oesophagus was approached from the right thorax in all cases and only in one of them the operation was not completed due to hemodynamic instability. There were 145/195 (75%) Spitz group I patients; 44/195 (22%) were group II and 6/195 (3%) group III. The mortality was respectively 9.5, 59 and 83%. We lost 15/113 (13%) babies with EA without CHD, 4/39 (10.2%) with EA and CHD and 26/43 (60%) with EA and MCHD. In children with CHD diagnosed prior to the esophageal operation 8/26 (30.7%) died and among those without diagnoses 3/12 (25%) died, (chi2 P > 0.1). 1. CHD was diagnosed after EA repair in one-third of cases. 2. Preoperative diagnosis of CHD changed the operative indication only in one case. 3. Survival after treatment for EA was not influenced by the moment or the accuracy of the diagnosis of CHD in this series. 4. With only a few exceptions, associated CHD should not change the strategies of EA repair.

Cardiac magnetic resonance imaging for accurate diagnosis of aortic arch anomalies in patients with 22q11.2 deletion

This study demonstrates, in patients with 22q11.2 deletion, the wide variety of complex aortic arch anomalies that can be accurately defined by cardiac magnetic resonance imaging (MRI) compared with echocardiography. From May 1999 to August 2003, 17 of 68 patients (25%) with 22q11.2 deletion referred for cardiac evaluation required cardiac MRI, after echocardiography, to clarify aortic arch anatomy. Images of cardiac anatomy were obtained using steady-state free precession, half-Fourier acquired single turbo spin-echo dark blood sequences and gadolinium for 3-dimensional reconstruction. All MRI findings were abnormal, and in 16 of 17 cases, echocardiography was unable to define aortic arch anomalies correctly compared with MRI.

Preoperative and postoperative evaluation of airways compression in pediatric patients with 3-dimensional multislice computed tomographic scanning: Effect on surgical management

OBJECTIVES

Surgical management of airway compression of vascular origin requires an accurate analysis of anatomy and various mechanisms of compression. This study assessed the usefulness of 3-dimensional computed tomographic scanning in the preoperative and postoperative evaluation of airways compression in a pediatric population.

METHODS

Thirty-seven consecutive patients (median age, 4 months) were examined with multislice 3-dimensional computed tomographic scanning: 18 patients before surgical treatment of anomalies of vascular rings, 2 patients because of respiratory symptoms after repair of esophageal atresia, and 17 patients because of persisting respiratory symptoms or prolonged mechanical ventilation after cardiac surgery for congenital heart disease.

RESULTS

The procedure was successful, with high-quality diagnostic imaging obtained in all cases without any complications. The anatomy and relationship between the vascular arches and airways was analyzed in all referred patients with vascular arch anomalies confirmed on the basis of the surgical findings, and this helped the surgeon to plan the procedure and choose the best approach. After cardiac surgery, the airway and vascular structures involved and the mechanism of compression were specified in all but one case, and the 3-dimensional computed tomographic scan serves as an important tool for deciding whether to perform reoperation on patients requiring prolonged mechanical ventilation.

CONCLUSION

Three-dimensional computed tomographic scanning is a safe, fast, and noninvasive method useful for accurately analyzing the mechanisms of airway compression of vascular origin and thus possible improving the surgical management of pediatric patients.

Video-Assisted Thoracoscopic Division of Vascular Rings in Pediatric Patients

Vascular rings are usually repaired via left thoracotomy. We report our series of pediatric patients with vascular rings that were repaired thoracoscopically. From February 2002 to September 2004, 13 patients underwent video-assisted thoracoscopic surgical techniques (VATS) division of their vascular ring. Chest magnetic resonance arterography (MRA) and/or computed tomographic arteriography (CTA) were used to evaluate the vascular ring in most patients. Patients were chosen for VATS repair based on surgeon's choice and type of vascular ring. Data are expressed as mean ± SD. The Children's Healthcare of Atlanta Institutional Review Board approved this retrospective chart review. Age and weight was 1.5 ± 1.8 years (range: 4 months–17 years) and 16.0 ± 12.5 kg (range: 6.0–22.1 kg), respectively (n = 13). Associated diseases included congenital heart disease (n = 2). Symptoms included respiratory complaints (n = 6), dysphagia (n = 2), dysphagia and shortness of breath (n = 1), pneumonia (n = 2), tracheal deviation (n = 1), and one patient was asymptomatic. Vascular ring types included double aortic arch (n = 4) and right aortic arch with an aberrant left subclavian artery and a left ligamentum arteriosum (n = 9). Operating time was 70 ± 20 minutes (range: 46–122 minutes). One patient had to be opened because of a large arch. Length of stay was 1.9 ± 0.9 days (range: 1–3 days). There were no complications, and all patients improved clinically at follow-up. Thoracoscopic repair of certain types of vascular rings seems to be safe and effective in children. More patients, however, need to be studied.

A right-sided aortic arch misdiagnosed as asthma since childhood

Congenital malformation of the aortic arch complex occurs in 3% of humans. These vascular aberrations result from embryonic structures that persist when there is incomplete atrophy or regression during normal development. Typically, anomalies of the aortic arch do not cause respiratory symptoms. However, in some individuals, the unusual position of the remnant vessels may compress the airway and cause airflow limitation. As might be expected, a symptomatic vascular anomaly is most often clinically apparent in childhood. We report an adult male with exertional dyspnea who had been diagnosed with asthma since childhood. After his symptoms proved refractory to newer asthmatic therapy, he was referred for further evaluation. Bronchial hyperactivity was not present with objective testing, and compression of his trachea by a right-sided aortic arch was confirmed with appropriate imaging studies. This report illustrates the need to confirm the diagnosis of asthma with objective measures of airflow and reminds the clinician that a congenital vascular aberrancy may initially elude diagnosis.

Cardiovascular causes of airway compression

Compression of the paediatric airway is a relatively common and often unrecognized complication of congenital cardiac and aortic arch anomalies. Airway obstruction may be the result of an anomalous relationship between the tracheobronchial tree and vascular structures (producing a vascular ring) or the result of extrinsic compression caused by dilated pulmonary arteries, left atrial enlargement, massive cardiomegaly, or intraluminal bronchial obstruction. A high index of suspicion of mechanical airway compression should be maintained in infants and children with recurrent respiratory difficulties, stridor, wheezing, dysphagia, or apnoea unexplained by other causes. Prompt diagnosis is required to avoid death and minimize airway damage. In addition to plain chest radiography and echocardiography, diagnostic investigations may consist of barium oesophagography, magnetic resonance imaging (MRI), computed tomography, cardiac catheterization and bronchoscopy. The most important recent advance is MRI, which can produce high quality three-dimensional reconstruction of all anatomic elements allowing for precise anatomic delineation and improved surgical planning. Anaesthetic technique will depend on the type of vascular ring and the presence of any congenital heart disease or intrinsic lesions of the tracheobronchial tree. Vascular rings may be repaired through a conventional posterolateral thoracotomy, or utilizing video-assisted thoracoscopic surgery (VATS) or robotic endoscopic surgery. Persistent airway obstruction following surgical repair may be due to residual compression, secondary airway wall instability (malacia), or intrinsic lesions of the airway. Simultaneous repair of cardiac defects and vascular tracheobronchial compression carries a higher risk of morbidity and mortality.

MRA of the thoracic vessels

Magnetic resonance imaging (MRI) is well suited for the noninvasive evaluation of the thoracic vasculature, and with improvements in scanner technology, the ability of MR to illustrate the thoracic vessels has significantly improved. Dedicated vascular software and pulse sequences have become commercially available, and fast imaging, in particular, has facilitated the time-efficient and comprehensive MR evaluation of most thoracic vascular lesions. Over the years, a host of black and bright blood MRI methods have evolved into practical tools for illustration of the thoracic vessels. As with other MR applications, successful vascular depiction relies significantly on the proper selection and prescription of imaging pulse sequences. In this article, these methods with their specific technical and practical pitfalls for thoracic magnetic resonance angiography (MRA) will be discussed. Current clinical indications for thoracic MRA will also be illustrated.

Diverticulum of Kommerell: a review of a series and a report of a case with tracheal deviation compromising single lung ventilation

IMPLICATIONS

Birth defects can affect the great vessels of the aorta and its branches, compressing the upper airway and the swallowing track. Surgical repair of these defects requires manipulating the airway to improve surgical exposure. This is a report of a series of cases with compromised airway resulting from such a birth defect and methods of its management.

Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience

BACKGROUND

Vascular rings are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this report, we offer a description of our approach and a review of our 25-year experience.

METHODS

A retrospective review was conducted of all pediatric patients with symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1974 to 2000.

RESULTS

Thirty-one patients (38%) of eighty-two patients (mean age, 1.7 years), were identified with double aortic arch, 22 patients (27%) with right arch left ligamentum, and 20 patients (24%) with innominate artery compression. Our diagnostic approach emphasized barium esophagram, along with echocardiography. This regimen was found to be reliable for all cases except those with innominate artery compression for which bronchoscopy was preferred, and except those with pulmonary artery sling for which computed tomography or magnetic resonance imaging, in addition to bronchoscopy, were preferred. Left thoracotomy was the most common operative approach (70 of 82; 85%). Ten patients (12%) had associated heart anomalies, and 6 (7%) patients underwent repair. Complications occurred in 9 (11%) patients and led to death in 3 (4%) patients.

CONCLUSIONS

In our practice, barium swallow and echocardiography are sufficient in diagnosing and planning the operative strategy in the majority of cases, with notable exceptions. Definitive intraoperative delineation of arch anatomy minimizes the risk of misdiagnosis or inadequate treatment.

Three-dimensional imaging of aortic arch anomalies in infants and children with intravascular ultrasound catheters from a transesophageal approach

Aortic arch anomalies usually require surgical intervention preceded by precise anatomic definition. We studied 20 patients to evaluate the feasibility and accuracy of using intravascular ultrasound catheters from a transesophageal approach with 3-dimensional image reconstruction for the diagnosis of aortic arch anomalies in infants and children. All patients had transthoracic echocardiograms and/or angiograms or magnetic resonance imaging. A 12.5-MHz intravascular ultrasound catheter was positioned in the esophagus and withdrawn by using an electrocardiogram and a respiratory gated pullback device to acquire the mediastinal images. All patients with arch anomalies underwent surgical repair. Reconstructed images were analyzed in the "anyplane" mode and with surface rendering. Intravascular ultrasound 3-dimensional imaging was successfully accomplished without complications. Anatomy was correctly identified in all patients by both blinded and unblinded observers, thus confirming the sensitivity and accuracy of the technique. We foresee this new technique to be useful as an adjunctive imaging modality applicable at the bedside or in the cardiac imaging laboratory.

Symptomatic vascular rings in adulthood: an uncommon mimic of asthma

Symptomatic thoracic vascular rings presenting in adulthood are thought to be rare. During a 3-year time period, we diagnosed four cases of symptomatic vascular rings, which had been treated unsuccessfully for suspected asthma. Spirometry was characterized by normal forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1), and FEV1/FVC, decreased peak expiratory flow (PEF), and truncation of the expiratory flow volume loop. Chest radiographs revealed a right aortic arch in each case with computed tomography (CT) or magnetic resonance imaging (MRI) confirming the diagnosis of a vascular ring. The specific abnormalities consisted of right aortic arch with mirror branching of the main arteries and persistent ligamentum arteriosum; right aortic arch with diverticulum and a fibrous embryonic left arch; right aortic arch with aberrant left subclavian artery arising from a diverticulum of Kommerell; and a right aortic arch with persistent ligamentum arteriosum. Although they are uncommon, vascular rings first presenting in adulthood as a mimic of asthma are not rare. This diagnosis should be considered in adults when abnormal truncation of the flow-volume loop occurs or when radiographic aortic arch abnormalities are found.

Concomitant management of airway and its adjacent vascular pathology in addition to repair of congenital cardiac defects

Respiratory symptoms are often present in infants with congenital cardiac anomalies, but the intrinsic pathology of the airway itself or external compression by abnormal vessels is frequently undetected before cardiac repair. We collected 12 patients with airway pathology from July 1996 to October 1998; all had definite diagnosis of lesions of the airway and its adjacent vessels by preoperative ultrafast computed tomography. Four had intrinsic pathology (one retrotracheal diverticulum, three tracheal stenosis) as well as external compression. Among them, six had complete vascular ring, four partial rings and three had bronchial compression by aneurysmal dilatation of branch pulmonary arteries. Simultaneous airway repair (one diverticulectomy, three patch tracheoplasty) and external decompression were performed in ten cases under cardiopulmonary bypass, nine of ten had simultaneous cardiac repair; the other two were done before cardiac repair. All survived except three. We concluded that ultrafast computed tomography is indispensable for definite diagnosis of airway and adjacent cardiovascular pathology. Mere repair of congenital cardiac defects without rectification of the airway and its adjacent structures is incompatible with survival.

Spiral CT versus MRI in neonatal airway evaluation

Magnetic resonance imaging has become the standard means of imaging pediatric airway obstruction due to vascular anomalies. However, magnetic resonance imaging requires a long acquisition time and is prone to motion artifacts. The development of spiral or helical computed tomography provides an alternative imaging modality for evaluating pediatric airway obstruction. We present the case of a neonate with a double aortic arch which initially was not identified on magnetic resonance imaging but was visualized with spiral computed tomography. If suspicion of an intra-thoracic abnormality is high, spiral computed tomography may be a useful adjunct or replacement to magnetic resonance imaging.