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Berry CM, Padilla LA, Sorabella R, Dabal RJ, Shah S, Nkengbeza LN, Gray WH. Outcomes for Children With Vascular Ring Repair Using a Simple Surgical Approach. J Surg Res 2024; 301:392-397. [PMID: 39029262 DOI: 10.1016/j.jss.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/23/2024] [Accepted: 06/23/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION Vascular Rings (VRs) are congenital malformations of the aortic arch that can compress the trachea and esophagus producing symptoms. Approximately, 5%-10% of patients experience persistent symptoms postrepair and 9% require reintervention. There are various approaches to repair-simple ligation and division of the ring or more complex procedures. Our objective was to describe outcomes for VR repair using a "simple" surgical approach. METHODS We identified patients who underwent VR repair from 2012 to 2022 at our institution. Clinical and surgical data, demographics, intraoperative, and postoperative outcomes were extracted from their electronic medical records. Outcomes were analyzed and regression analysis was used to identify risk factors for residual symptoms after repair. RESULTS Ninety three patients with VR repair were included. Prevalence of symptoms were reduced following surgery (80% preoperative versus 13% postoperative, P 0.03). Tracheomalacia also decreased from 16% to 7% postrepair. No deaths were reported in our cohort and 2% of our patients required reintervention. Multivariable regression analysis showed that preoperative tracheomalacia was associated with having persistent symptoms after VR repair (odds ratio 6.2, 95% CI 1.02-37.6). CONCLUSIONS Our institutional experience using a simple surgical approach showed a significant decrease in symptoms, a very low reintervention rate and no mortality. Preoperative tracheomalacia can be a risk factor for persistent symptoms postrepair. We believe a simple surgical approach for children with complete VR repair can be effective in relieving symptoms.
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Affiliation(s)
- C Mason Berry
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert Sorabella
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shefali Shah
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Leopold N Nkengbeza
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - W Hampton Gray
- Division of Cardiothoracic Surgery, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama.
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Bartoli CR, Rajakumar CJ, Elmore JR, Ziemer G. Contralateral Thoracotomy With Extracorporeal Circulation for Reoperative Resection of a Kommerell Diverticulum. World J Pediatr Congenit Heart Surg 2024; 15:242-245. [PMID: 38378189 DOI: 10.1177/21501351231224385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Reoperative vascular ring surgery is uncommon. Standard redo ipsilateral thoracotomy may present technical challenges and risks. We describe a patient with right aortic arch, aberrant left subclavian artery, and a Kommerell diverticulum in whom previous vascular ring division via left thoracotomy did not relieve dysphagia. Three years after the unsuccessful operation, left subclavian-carotid transposition via supraclavicular incision followed by resection of the Kommerell diverticulum via right thoracotomy with extracorporeal circulation relieved symptoms. Contralateral thoracotomy with extracorporeal circulation provides a safe, alternative approach to redo ipsilateral thoracotomy for resection of a symptomatic Kommerell diverticulum. We review the literature on the incidence, surgical indications, and operative approaches to manage symptoms from a Kommerell diverticulum.
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Affiliation(s)
- Carlo R Bartoli
- Division of Cardiothoracic Surgery, Geisinger Medical Center, Danville, PA, USA
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | | | - James R Elmore
- Division of Vascular Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Gerhard Ziemer
- Division of Cardiothoracic Surgery, Geisinger Medical Center, Danville, PA, USA
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Backer CL, Mongé MC, Wallen WJ, Eltayeb O. The aortic uncrossing procedure. J Thorac Cardiovasc Surg 2024; 167:413-419. [PMID: 37406764 DOI: 10.1016/j.jtcvs.2023.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/01/2023] [Accepted: 06/10/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic arch from right to left posterior to the trachea and superior to the carina in a patient with a right aortic arch. We evaluated our patients who received an aortic uncrossing procedure. METHODS We reviewed all patients who underwent aortic uncrossing from 2002 to 2022. All patients received preoperative computed tomography imaging and bronchoscopy. RESULTS Eleven patients ranging in age from 1.5 to 10 years (median 4 years) underwent aortic uncrossing. Two patients had prior left ligamentum division, and 3 patients had prior left aortic arch division. All had significant clinical symptoms. Eight patients had deep hypothermic circulatory arrest (mean 34 minutes), and 3 patients had antegrade cerebral perfusion (median, 28 minutes). Patch material was not used for aortic augmentation, and no patient underwent a posterior tracheopexy or rotational esophagoplasty. Postoperative length of stay ranged from 4 to 31 days (median, 5 days). One patient required a temporary tracheostomy for bilateral recurrent laryngeal nerve paresis, which recovered. One patient required an aortic extension graft to alleviate esophageal compression from an unusual ectatic esophageal course. All patients had relief of airway symptoms and dysphagia. CONCLUSIONS In properly selected patients with a right aortic arch and circumflex aorta, aortic uncrossing is a safe and effective therapy to treat airway and esophageal compression. The procedure can be conducted with deep hypothermic circulatory arrest or antegrade cerebral perfusion. Careful attention to the location of the esophagus and recurrent laryngeal nerves is required.
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Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, Ohio.
| | - Michael C Mongé
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert J. Lurie, Children's Hospital of Chicago, Chicago, Ill; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - William J Wallen
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, Ohio
| | - Osama Eltayeb
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert J. Lurie, Children's Hospital of Chicago, Chicago, Ill; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
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4
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Geoffrion TR. Commentary: Aortic uncrossing: First time's a charm? J Thorac Cardiovasc Surg 2024; 167:420-421. [PMID: 37473995 DOI: 10.1016/j.jtcvs.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Tracy R Geoffrion
- Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Wisconsin, Milwaukee, Wis; Division of Congenital Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis.
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5
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Rato J, Zidere V, François K, Boon M, Depypere A, Simpson JM, Speggiorin S, Vigneswaran TV. Post-operative Outcomes for Vascular Rings: A Systematic Review and Meta-analysis. J Pediatr Surg 2023; 58:1744-1753. [PMID: 36967253 DOI: 10.1016/j.jpedsurg.2023.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 01/22/2023] [Accepted: 02/11/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Vascular rings may cause tracheal and/or oesophageal compression. For many patients, symptoms/signs have been present for a long period before diagnosis. However, in the era of prenatal diagnosis, some units advocate universal early surgery. The risks and efficacy of surgery must be known to adequately counsel for the operation. This meta-analysis sought to define the morbidity and mortality associated with surgical correction, and persistent post-operative symptoms. METHODS PubMed, Cochrane Library and CINAHL databases were searched for studies that described the outcome of patients undergoing surgery for a double or right aortic arch (DAA or RAA). Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled rates of mortality, surgical complications, reintervention, and persistent follow-up symptoms. RESULTS Nineteen eligible studies were included comprising 18 studies describing outcomes for DAA surgery and 15 for RAA surgery. For DAA surgery, overall mortality rate was 0% [95% confidence interval (CI) 0.0-1.0], post-surgical complication rate 18% [95% CI: 12.0-23.0], prevalence of reintervention 3% [95% CI: 1.0-5.0] and prevalence of symptoms at last follow-up was 33% [95% CI: 17.0-52.0]. For RAA surgery, overall pooled mortality was 0% [95% CI: 0.0-0.0], prevalence of post-surgical complications was 15% [95% CI: 8.0-23.0], reintervention rate was 2% [95% CI: 0.0-4.0], prevalence of symptoms at last follow-up was 40% [95% CI: 26.0-55.0]. CONCLUSIONS While surgery to correct a vascular ring is safe, the rate of persistent symptoms is high and further strategies must be sought to reduce this burden.
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Affiliation(s)
- Joao Rato
- Department of Pediatric Cardiology, Hospital de Santa Cruz - Centro Hospitalar Universitário Lisboa Ocidental, Carnaxide, Portugal; Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK.
| | - Vita Zidere
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK; Harris Birthright Centre, Fetal Medicine Research Institute, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | | | - Mieke Boon
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Gasthuisberg Leuven, Belgium
| | - Anouk Depypere
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Gasthuisberg Leuven, Belgium
| | - John M Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK; School of Biomedical Engineering & Imaging Sciences, King's College London, London, SE1 7EH, UK
| | - Simone Speggiorin
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Trisha V Vigneswaran
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK; School of Biomedical Engineering & Imaging Sciences, King's College London, London, SE1 7EH, UK
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Hurtado CG, Nelson JS. Concurrent double aortic arch and circumflex aorta repair in a symptomatic child: a case report. J Cardiothorac Surg 2022; 17:148. [PMID: 35672840 PMCID: PMC9175390 DOI: 10.1186/s13019-022-01907-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractDouble aortic arch with circumflex aorta is a rare type of vascular ring. Symptoms result from external compression of the trachea and esophagus. The best surgical approach for patients with double arch and circumflex aorta is debated, and options include the highly complex aortic uncrossing procedure. Herein we describe the surgical treatment of a patient with concurrent double aortic arch and circumflex aorta by division of the non-dominant arch and ligamentum arteriosum, plication and posterior tacking of the diverticulum of Kommerell. This left thoracotomy approach provided complete symptom resolution.
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7
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Fisenne DT, Burns J, Dhar A. Feeding Difficulties Following Vascular Ring Repair: A Contemporary Narrative Review. Cureus 2022; 14:e24623. [PMID: 35651405 PMCID: PMC9138490 DOI: 10.7759/cureus.24623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/30/2022] [Indexed: 11/24/2022] Open
Abstract
Vascular rings are congenital abnormalities of the aortic arch vascular system that compress the trachea and esophagus. A review of long-term outcomes suggests that chronic feeding difficulties can persist following surgical repair of vascular rings. Previous reports of postoperative vascular ring division outcomes indicate that chronic esophageal symptoms may persist following repair, though most available data focuses on persistent respiratory symptoms. It is therefore the aim of this article to summarize and organize recent evidence reporting the frequency, presentation, and management of feeding difficulties following vascular ring repair in pediatric patients. Pathophysiologic mechanisms for postoperative esophageal symptoms may include residual compression from an unresected diverticulum of Kommerell or delayed repair leading to chronic esophageal dysmotility despite correction of esophageal compression. Guidance on the management of feeding difficulties following vascular ring repair is limited. The authors describe success in one case with nasogastric tube feeding and interdisciplinary evaluation. Consensus regarding the management of feeding difficulty following vascular ring repair is needed.
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Beeman A, Ramaswamy M, Srinivasan Y, Rudrappa S, Christov G, Marek J, Derrick G, Muthialu N. Importance of Acute Anterior Angulation in Double Aortic Arch Needing Attention at Primary Surgery. Front Cardiovasc Med 2022; 8:760523. [PMID: 35141288 PMCID: PMC8818705 DOI: 10.3389/fcvm.2021.760523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 11/29/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundVascular rings are rare congenital abnormalities of the aortic arch. There are many embryological variants including a double aortic arch. In symptomatic children, division of ring and release of airway structures may be sufficient. Persistence of symptoms can be related to an anterior angle formed between the two arches. The aim of this study is to evaluate the clinical efficacy in improving symptoms and on changing this angle at the primary surgery.MethodsAll children who had surgery for double aortic arch between 2005 and 2020, were studied. Relevant factors were analyzed for persistent symptoms including anatomical substrates and surgical details.ResultsA total of 87 out of 224 children had surgery for a double aortic arch. At presentation, airway symptoms (n = 74/87) were more common than esophageal symptoms (n = 27/87). Early onset symptoms within 1 year were seen in 49 children. In addition to division of one arch, surgical steps also included realigning the anterior left arch, thereby eliminating the acute angle in 36 children (after 2014). After surgery, symptom relief within 12 months following surgery was seen in 64% of children (56 out of 87) but in 27 out of 36 children (75%) with additional surgical modification, as against 29 out of 51 (57%) in those with division of the arch. Symptoms persisted beyond 1 year needing reintervention in eight children.ConclusionAnterior arch angulation plays an important role in double aortic arch by causing a “nutcracker” phenomenon. Repair in double aortic arch should consider this aspect and include modification of surgical steps by realigning the corresponding aortic arch branches and an anterior pexy in selected cases.
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9
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Backer CL. The vascular ring decision tree. Eur J Cardiothorac Surg 2021; 62:6459585. [PMID: 34894130 DOI: 10.1093/ejcts/ezab525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, KY, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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10
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Amir G, Soffair N, Bruckheimer E, Nachum E, Shoenfeld T, Rotstein A, Frenkel G, Birk E. Mid-term results of vascular ring surgery. Cardiol Young 2021; 32:1-6. [PMID: 34776035 DOI: 10.1017/s1047951121004224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery. METHODS Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time. RESULTS Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bronchodilator use,18.3% had at least one episode of pneumonia per year, 31% of children had dyspnoea or respiratory limitation, and 12.7% while doing physical activities. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. CONCLUSIONS Surgical division of vascular rings results in significant clinical improvement within 1 year; nevertheless, some patients remain symptomatic to some degree. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Further evaluation is warranted to assess the nature of residual symptoms and explore whether anatomical causes can be identified leading to surgical modifications.
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Affiliation(s)
- Gabriel Amir
- Division of Pediatric and Congenital Cardiac Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Niv Soffair
- Division of Pediatric and Congenital Cardiac Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elchanan Bruckheimer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Elchanan Nachum
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Tommy Shoenfeld
- Pediatric Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Amichai Rotstein
- Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Georgy Frenkel
- Division of Pediatric and Congenital Cardiac Surgery, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Einat Birk
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Cardiology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
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Labuz DF, Kamran A, Jennings RW, Baird CW. Reoperation to correct unsuccessful vascular ring and vascular decompression surgery. J Thorac Cardiovasc Surg 2021; 164:199-207. [PMID: 34922756 DOI: 10.1016/j.jtcvs.2021.08.089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Although most children do well after operations to relieve vascular compression of the esophagus and airway, many will have persistent/recurrent symptoms. We review our surgical experience using a customized approach to correct various etiologies of failure after vascular ring/decompression surgery. METHODS Our institutional database identified children who underwent reoperation for persistent/recurrent symptoms after vascular ring or aberrant arterial decompression surgery between January 2014 and December 2019. Charts were reviewed for operative approaches and clinical data. Findings were analyzed by Fisher exact test for comparison between groups. RESULTS Twenty-seven children required reoperative surgery. Detailed preoperative workup identified 5 etiologies of failure for a customized approach. Residual scarring was corrected by lysis and rotational esophagoplasty (n = 23/27); fibrotic bands re-creating a ring were divided (n = 11); ongoing vascular compression was addressed by descending aortopexy (n = 19), aberrant subclavian division (n = 7), aortic uncrossing procedure (n = 4), and Kommerell resection (n = 8); anterior aortopexy (n = 6) and anterior tracheopexy (n = 9) corrected cartilage malformation; and tracheobronchomalacia was addressed with posterior airway pexy (n = 26). At available short-term follow-up (median 1 year), 21 of 22 patients (95%) had symptom improvement, and on bronchoscopy, the average number of airway sections with severe tracheobronchomalacia decreased from 2.8 ± 1.7 to 0.5 ± 0.9 (P < .001). CONCLUSIONS Persistent/recurrent symptoms after release of vascular compression are frequently caused by 5 different etiologies. A multidisciplinary strategy for workup and a customized operative approach can effectively treat these cases and may suggest opportunity at the index surgery to prevent reoperation and achieve optimal outcomes.
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Affiliation(s)
- Daniel F Labuz
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Ali Kamran
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Russell W Jennings
- Department of General Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
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Yu D, Guo Z, You X, Peng W, Qi J, Sun J, Wu K, Li X, Mo X. Long-term outcomes in children undergoing vascular ring division: a multi-institution experience. Eur J Cardiothorac Surg 2021; 61:605-613. [PMID: 34632492 PMCID: PMC8858591 DOI: 10.1093/ejcts/ezab432] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Vascular rings are rare anomalies of congenital heart disease that cause respiratory and gastrointestinal symptoms. This study assessed the long-term outcomes of patients with vascular ring division. METHODS A multi-institution retrospective review of 371 patients with vascular rings undergoing surgical division at 3 paediatric cardiac institutions between November 2007 and October 2019 was performed. RESULTS The complete vascular rings consisted of a double aortic arch (24.5%), right aortic arch with left ligamentum arteriosum (36.7%) and left aortic arch, with right ligamentum arteriosum (0.5%). The incomplete vascular rings consisted of a pulmonary artery sling (22.9%), left aortic arch with aberrant right subclavian artery (15.1%) and innominate artery compression syndrome (0.3%). Respiratory symptoms included stridor (71.4%), wheezing (49.1%), coughing (31.5%), gastrointestinal symptoms included choking (12.4%), dysphagia (3.2%) and emesis (1.9%). Only one patient died after discharge, yielding a late mortality rate of 0.3% (1/360). The 10-year overall survival rate was 96.8%. Postoperative complications were reported in 51 patients, 15 of whom required reoperation. The 10-year freedom from reoperation rate was 95.9%. Follow-up was completed in 95.4% (354/371) of patients, with a mean follow-up time of 4.3 ± 2.9 years (range from 1 to 13 years). Twenty patients (5.6%) experienced residual symptoms during long-term follow-up. CONCLUSIONS The outcomes of vascular ring division are excellent. A Kommerell diverticulum >1.5 times the aberrant left subclavian artery origin is an operative indication for primary resection. Tracheomalacia is a risk factor for reoperation and residual symptoms, and preoperative fibrobronchoscopy is important for evaluation.
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Affiliation(s)
- Di Yu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Zhangke Guo
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xin You
- Department of Cardiac Surgery, Children's Hospital of Suqian, Suqian, China
| | - Wei Peng
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jirong Qi
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Sun
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Kaihong Wu
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaofeng Li
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xuming Mo
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
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13
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Imamura M. Commentary: Do we need such aggressive treatment? J Thorac Cardiovasc Surg 2021; 164:209-210. [PMID: 34563371 DOI: 10.1016/j.jtcvs.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Michiaki Imamura
- Congenital Heart Surgery, Texas Children's Hospital, Houston, Tex.
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14
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Backer CL. Commentary: Vascular ring repair: Not always one and done. J Thorac Cardiovasc Surg 2021; 164:208-209. [PMID: 34548156 DOI: 10.1016/j.jtcvs.2021.08.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
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15
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Biermann D, Holst T, Hüners I, Rickers C, Kehl T, Rüffer A, Sachweh JS, Hazekamp MG. Right aortic arch forming a true vascular ring: a clinical review. Eur J Cardiothorac Surg 2021; 60:1014-1021. [PMID: 33970211 DOI: 10.1093/ejcts/ezab225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/02/2021] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This review aims at presenting and summarizing the current state of literature on the presentation and surgical management of a right-sided aortic arch with a left-sided ligamentum forming a complete vascular ring around the oesophagus and trachea. METHODS A systematic database search for appropriate literature was conducted on PubMed/MEDLINE. Articles were considered relevant when providing details on the presentation, diagnosis and surgical treatment of this specific congenital arch anomaly in human beings. RESULTS Affected patients present with respiratory and/or oesophageal difficulties due to tracheoesophageal compression. Conservative treatment might be reasonable in asymptomatic or mildly symptomatic cases; however, once moderate-to-severe symptoms develop, surgical intervention is definitely indicated. Surgery is commonly performed through a left thoracotomy or median sternotomy and includes the division of the left ductal ligamentum; if a Kommerell's diverticulum is present that is >1.5 times the diameter of the subclavian artery, then concomitant resection of the large diverticulum and translocation of the aberrant left subclavian artery is also conducted. Postoperative morbidity and mortality are low and are rather related to concomitant intracardiac and extracardiac anomalies than to the procedure itself. In a majority of patients, full resolution of symptoms is seen within months to years from the surgery. Nevertheless, there is also a subset of patients who remain with some tracheobronchial narrowing, sometimes even requiring reintervention during follow-up due to persisting or recurring symptoms. CONCLUSIONS Overall, the surgical management of a right aortic arch forming a true vascular ring in infancy, childhood and adulthood seems relatively safe and effective in providing symptomatic relief despite some persistent tracheobronchial and/or oesophageal narrowing in some cases.
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Affiliation(s)
- Daniel Biermann
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.,Surgery for Congenital Heart Disease, University Heart and Vascular Center, Hamburg, Germany
| | - Theresa Holst
- Surgery for Congenital Heart Disease, University Heart and Vascular Center, Hamburg, Germany
| | - Ida Hüners
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands.,Surgery for Congenital Heart Disease, University Heart and Vascular Center, Hamburg, Germany
| | - Carsten Rickers
- Adult Congenital Heart Disease Section, University Heart and Vascular Center, Hamburg, Germany
| | - Torben Kehl
- Department of Pediatric Cardiology, University Heart and Vascular Center, Hamburg, Germany
| | - André Rüffer
- Surgery for Congenital Heart Disease, University Heart and Vascular Center, Hamburg, Germany
| | - Jörg S Sachweh
- Surgery for Congenital Heart Disease, University Heart and Vascular Center, Hamburg, Germany
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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16
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Haranal M, Srimurugan B, Sivalingam S. Circumflex aorta: An uncharted territory. Asian Cardiovasc Thorac Ann 2021; 30:217-225. [PMID: 33957784 DOI: 10.1177/02184923211015092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vascular rings are aortic arch anomalies with a spectrum of manifestations ranging from asymptomatic lesions detected incidentally to an acute presentation secondary to tracheo-esophageal compression. Circumflex retro-esophageal aortic arch is an extreme form of true vascular ring. It remains an uncharted territory to many surgeons. METHODS A comprehensive search of peer reviewed journals was completed based on the key words, "Circumflex aorta," "Circumflex retro-esophageal aorta" and "circumflex arch" using Google scholar, Scholars Portal Journals and PubMed. The reference section for each article found was searched to obtain additional articles. Literature on the circumflex aorta was reviewed starting from the embryogenesis to the latest management strategies. RESULTS Right circumflex aorta is more prevalent compared to left circumflex aorta. It can occur in isolation or in association with other intracardiac lesions. Mainly presents in children, however reported in adults too. The presentation may vary from asymptomatic lesion to acute respiratory distress secondary to airway compression. Computerized tomography (CT) and magnetic resonance imaging (MRI) are important tools in delineating the vascular anatomy. Aortic uncrossing is the definitive procedure. However, the role of concomitant tracheobronchopexy is emerging. Native tissue-to-tissue anastomosis is commonly preferred, but cases of extra-anatomic grafts are reported. CONCLUSION Circumflex aorta is amenable to complete repair. Preoperative delineation of anatomy is important for successful surgical outcome. Division of the retro-esophageal segment is crucial in relieving the compressive symptoms. In addition, tracheobronchopexy is helpful in addressing residual tracheomalacia but this accounts for a high-risk surgery.
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Affiliation(s)
- Maruti Haranal
- Department of Cardiac Surgery, National Heart Institute, Kuala Lumpur, Malaysia
| | - Balaji Srimurugan
- Department of Pediatric Cardiac Surgery, Amrita Institute of Medical Sciences, Kochi, India
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17
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Sang CJ, Hebson C. Noisy Breathing in an Infant: A Case Report. Cureus 2021; 13:e13015. [PMID: 33665045 PMCID: PMC7920572 DOI: 10.7759/cureus.13015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The diagnosis of vascular rings is challenging and may be delayed as symptoms overlap with more common conditions associated with childhood. Underlying genetic associations of this condition remain largely undiscovered. In this report, we present a patient with a double aortic arch and highlight the importance of diagnostic imaging. We also engage in a review of the important genetic considerations.
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Affiliation(s)
- Charlie J Sang
- Internal Medicine/Pediatrics, University of Alabama at Birmingham, Birmingham, USA
| | - Camden Hebson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, USA
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18
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Callahan CP, Merritt TC, Canter MW, Eghtesady P, Manning PB, Abarbanell AM. Symptom persistence after vascular ring repair in children. J Pediatr Surg 2020; 55:2317-2321. [PMID: 32005503 DOI: 10.1016/j.jpedsurg.2019.12.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/18/2019] [Accepted: 12/26/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE Vascular rings are often diagnosed after evaluation for swallowing and breathing difficulties. Data regarding symptoms following vascular ring repair is sparse. We sought to determine whether symptoms persist using chart review and a survey. METHODS Sixty-three patients underwent open vascular ring repair from July 2007 to May 2018. Data regarding vascular anatomy, demographics, pre- and postoperative symptoms, and chromosomal abnormalities were collected. Freedom from reoperation, 30-day mortality, and complications were assessed. Patient families were contacted for a symptom focused survey. RESULTS The median age of surgical intervention was 14.4 months (IQR 5.8-34.7 months) for single aortic arches with an aberrant subclavian artery (SAA), and 5.3 months (IQR 1.3-10.1 months) for double aortic arches (DAA) (Table). Prior to surgery, all but two SAA were symptomatic. There was no operative mortality. Three patients required re-exploration for chylothorax, and three required late aortopexy. At last follow-up, 45% (18/40) SAA and 65% (15/23) DAA had post-operative symptoms. Fourteen patient families completed the symptom survey (10 SAA, 4 DAA). Five SAA had breathing and swallowing symptoms, and 3 SAA and 3 DAA had breathing difficulties. CONCLUSIONS Open vascular ring repair remains a safe repair. However, further investigation of the persistent symptoms in these patients is merited. STUDY TYPE / LEVEL OF EVIDENCE Retrospective Comparative Study, Level III.
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Affiliation(s)
- Connor P Callahan
- Washington University School of Medicine, Department of Surgery, 660 S. Euclid, Campus Box 8109, St. Louis, MO 63110.
| | - Taylor C Merritt
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine; One Children's Place, Campus Box 8234, St. Louis, MO 63110
| | - Matthew W Canter
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine; One Children's Place, Campus Box 8234, St. Louis, MO 63110
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine; One Children's Place, Campus Box 8234, St. Louis, MO 63110
| | - Peter B Manning
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine; One Children's Place, Campus Box 8234, St. Louis, MO 63110
| | - Aaron M Abarbanell
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine; One Children's Place, Campus Box 8234, St. Louis, MO 63110
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19
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Said SM, Marey G, Knutson S, Rodgers N, Richtsfeld M, Joy B, Griselli M. Outcomes of Surgical Repair of Vascular Rings and Slings in Children: A Word for the Asymptomatic. Semin Thorac Cardiovasc Surg 2020; 33:492-500. [PMID: 32977012 DOI: 10.1053/j.semtcvs.2020.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
Vascular rings (VRs) are rare aortic arch anomalies that may present with a wide variety of symptoms related to esophageal and/or airway compression. We reviewed our surgical experience in both symptomatic and asymptomatic children. All children (n = 58) who underwent surgical repair of VRs or slings (mean age 27.4 ± 45.60 months; 36 males [62%]) between March 2000 and April 2020 were included. The most common anatomic variant was a right aortic arch (RAA) with aberrant left subclavian artery (ALSCA) (n = 29; 50%). Kommerell's diverticulum was present in 23 of these patients (79%). The second most common variant was a double aortic arch (n = 22; 38%), followed by pulmonary artery sling (n = 4; 6%), RAA with mirror image branching and left ligamentum arteriosum (n = 3; 5.2%), and left aortic arch (LAA) with aberrant right subclavian artery (n = 1; 1.7%). One patient had a double ring with pulmonary artery sling and RAA with ALSCA. Symptoms were present in 42 patients (72%). Left lateral thoracotomy was the approach in 50 patients (86%), while sternotomy was used in 8 (14%). Symptomatic improvement occurred in the majority of symptomatic patients (93%). There was one perioperative mortality (1.7%) in the symptomatic group which was non-VR related. Morbidities included recurrent laryngeal nerve injury in three patients (5.2%) and transient chylothorax in two (3.4%). Persistence/recurrence of symptoms resulted in one early and one late reoperation. The mean follow-up was 3 ± 5 years. In the current era, VR repair in children including asymptomatic ones can be performed with excellent results. We recommend complete repair of RAA with aberrant LSCA by resection of Kommerell's diverticulum and translocation of the ALSCA to avoid recurrence.
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Affiliation(s)
- Sameh M Said
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Department of Cardiothoracic Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Gamal Marey
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Stacie Knutson
- Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Nathan Rodgers
- Pediatric Cardiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Martina Richtsfeld
- Pediatric Anestheiology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Brian Joy
- Pediatric Critical Care, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Massimo Griselli
- Divisions of Pediatric Cardiovascular Surgery, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
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20
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Aortic uncrossing procedure: When the right becomes left. JTCVS Tech 2020; 4:239-242. [PMID: 34318027 PMCID: PMC8306938 DOI: 10.1016/j.xjtc.2020.09.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/17/2020] [Indexed: 11/30/2022] Open
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21
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Kamran A, Friedman KG, Jennings RW, Baird CW. Aortic uncrossing and tracheobronchopexy corrects tracheal compression and tracheobronchomalacia associated with circumflex aortic arch. J Thorac Cardiovasc Surg 2020; 160:796-804. [DOI: 10.1016/j.jtcvs.2020.03.158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 02/26/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022]
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22
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Mitchell ME. Commentary: A long haul and a short slide? J Thorac Cardiovasc Surg 2020; 160:807-808. [PMID: 32605733 DOI: 10.1016/j.jtcvs.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Michael E Mitchell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis; Division of Pediatric Cardiothoracic Surgery, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wis.
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23
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Backer CL. Commentary: Circumflex aorta: Entering uncrossed territory. J Thorac Cardiovasc Surg 2020; 160:805-806. [PMID: 32448687 DOI: 10.1016/j.jtcvs.2020.04.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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24
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Depypere A, Proesmans M, Cools B, Vermeulen F, Daenen W, Meyns B, Rega F, Boon M. The long-term outcome of an isolated vascular ring - A single-center experience. Pediatr Pulmonol 2019; 54:2028-2034. [PMID: 31456344 DOI: 10.1002/ppul.24490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/13/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of this study is to document the long-term outcome of patients with a vascular ring. METHODS A single-center retrospective review of clinical symptoms was conducted in all patients born between 1980 and 2013, diagnosed with a complete vascular ring and at least 2 years of follow-up. Data were extracted from patient files and clinical symptoms were assessed by questionnaires sent to the parents. Age and diagnostic tools, type of surgery, postoperative complications, and the prevalence of clinical symptoms (stridor at rest, stridor with exercise, cough, exercise intolerance, dysphagia, and frequent respiratory infections) were reviewed. RESULTS Fifty-one patients were included. The diagnosis was made before the age of 2 in 35/51. Surgery was performed in 41/51 patients with a limited number of reversible complications. The median follow-up was 8 (IQR 5-12) years. After 2 years, 21/51 patients were asymptomatic: 2/7 asymptomatic patients at diagnosis became symptomatic and symptoms resolved in 16/44 initially symptomatic patients. Consequently, 30/51 patients still had symptoms after 2 years. Of these, 16 had partial improvement, 5 stable symptoms, and 9 aggravation of symptoms. After 10 years, 26/36 patients were free of complaints. The most frequent long-term symptom was stridor. CONCLUSION Surgical treatment of a congenital vascular ring is safe and mostly performed in patients with a double aortic arch. Conservative treatment for patients with little symptoms seems to be justifiable. A considerable number of patients have residual long-term symptoms after surgical relief of the vascular ring.
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Affiliation(s)
- Anouk Depypere
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
| | - Marijke Proesmans
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
| | - Björn Cools
- Department of Pediatrics, Congenital Cardiology, University Hospital Leuven, Leuven, Belgium
| | - François Vermeulen
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
| | - Willem Daenen
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Mieke Boon
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
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25
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Abstract
A vascular ring is a rare congenital cardiovascular anomaly, which encircles and compresses the trachea or esophagus, or both. In this review we discuss the pathophysiology, theoretical embryopathogenesis, diagnostic modalities, and surgical treatment of the different types of vascular ring. Knowledge of the normal embryonic development of the aortic arch and related structures is important for understanding and classifying the various forms of vascular ring. The development of a vascular ring begins with the embryonic aortic arch system. The persistence, involution, or regression of the arches determines the multiple variations of vascular ring. With the development of new technologies, multi-detector computed tomography (MDCT) has become a good diagnostic modality for pre- and postoperative evaluation. MDCT provides an excellent image of aortic arch abnormalities and the related anatomy, as well as the tracheal pathology. For patients with symptoms, surgical division of the vascular ring usually achieves excellent outcomes with marked resolution of symptoms and a low risk of morbidity and mortality. Symptomatic vascular rings require early surgical intervention to prevent prolonged vascular compression of the airway and serious complications.
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26
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Alsaied T, Friedman K, Masci M, Hoganson DM, Baird CW, Geva T. Type B Interrupted Right Aortic Arch: Diagnostic and Surgical Approaches. Ann Thorac Surg 2019; 107:e41-e43. [PMID: 30009804 DOI: 10.1016/j.athoracsur.2018.05.098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/25/2022]
Abstract
Interrupted right aortic arch is a rare congenital cardiovascular anomaly typically associated with other forms of congenital heart disease. We report two cases of interrupted right aortic arch associated with isolated left pulmonary artery and bilateral ductus arteriosus in the first case and with truncus arteriosus in the second case. Computed tomography was complementary to echocardiography in delineating the anatomic details in both cases, informing surgical repair with reconstruction of a left aortic arch in the first case and right arch in the second case.
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Affiliation(s)
- Tarek Alsaied
- Department of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin Friedman
- Department of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Marco Masci
- Department of Pediatrics, Bambino Gesu Children's Hospital, Rome, Italy
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Tal Geva
- Department of Cardiology and Pediatrics, Boston Children's Hospital, Boston, Massachusetts.
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27
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Alsoufi B, Dydynski P, Austin E, Kozik D. Simultaneous Norwood and Aortic Uncrossing in Neonate With Aortic Atresia and Right Circumflex Aorta. Semin Thorac Cardiovasc Surg 2019; 32:563-568. [PMID: 31626912 DOI: 10.1053/j.semtcvs.2019.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky.
| | - Philip Dydynski
- Department of Radiology, Norton Children's Hospital, Louisville, Kentucky
| | - Erle Austin
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Deborah Kozik
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
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28
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Backer CL, Bharadwaj SN, Eltayeb OM, Forbess JM, Popescu AR, Mongé MC. Double Aortic Arch With Kommerell Diverticulum. Ann Thorac Surg 2019; 108:161-166. [DOI: 10.1016/j.athoracsur.2019.01.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 01/18/2019] [Accepted: 01/22/2019] [Indexed: 11/17/2022]
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29
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Binsalamah ZM, Chacon-Portillo MA, Sanyahumbi A, Adachi I, Heinle JS, Fraser CD, Mery CM. Circumflex aorta with double aortic arch in an infant. J Card Surg 2018; 33:292-295. [PMID: 29664156 DOI: 10.1111/jocs.13604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Circumflex aorta and double aortic arch are two forms of rare vascular rings. We present a case of an infant who was diagnosed with circumflex aorta and double aortic arch, and describe the surgical management of this rare anomaly.
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Affiliation(s)
- Ziyad M Binsalamah
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Martin A Chacon-Portillo
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Amy Sanyahumbi
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Iki Adachi
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jeffrey S Heinle
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Charles D Fraser
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carlos M Mery
- Congenital Heart Surgery and Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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30
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Naimo PS, Fricke TA, Donald JS, Sawan E, d'Udekem Y, Brizard CP, Konstantinov IE. Long-term outcomes of complete vascular ring division in children: a 36-year experience from a single institution. Interact Cardiovasc Thorac Surg 2017; 24:234-239. [PMID: 27798062 DOI: 10.1093/icvts/ivw344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/13/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives Complete vascular rings are rare and cause tracheoesophageal compression. Following surgical division, some patients have persisting tracheomalacia. We aim to assess the long-term outcomes of complete vascular ring division. Methods All patients (n = 132) who underwent surgical division of a complete vascular ring between 1978 and 2014 were identified from the hospital database and retrospectively reviewed. Results Complete vascular rings consisted of a double aortic arch (n = 80), right aortic arch with an aberrant subclavian artery and left ligamentum arteriosum (n = 50), right aortic arch with mirror image branching and left ligamentum arteriosum (n = 1), and a left aortic arch with right descending aorta and right ligamentum arteriosum (n = 1). Kommerell's diverticulum was identified in 10 patients. Preoperative tracheomalacia was identified via bronchoscopy in 25 patients. Concomitant tracheal reconstruction was not performed in any patient. Kommerell's diverticulum was resected in 1 patient. The hospital mortality rate was 1.5% (2/132). There were no late deaths. The overall survival rate was 98.3 ± 1.2% (95% CI: 93.4, 99.6) at 20 years. Postoperatively, persistent tracheal compression was reported in 3 patients, and tracheomalacia in 16 patients. The rate of freedom from reoperation was 88.6 ± 4.0% (95% CI: 77.9, 94.3) at 20 years. No patient required tracheal surgery during the follow-up period. Follow-up was 92% (121/132) complete, with a median follow-up of 11.4 years (range 44 days to 36 years). At the last follow-up, 7 patients had mild tracheomalacia. Conclusions Outcomes of division of a complete vascular ring are excellent. Tracheomalacia often improves following division of the vascular ring. Respiratory symptoms following complete vascular ring division are uncommon.
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Affiliation(s)
- Phillip S Naimo
- Royal Children's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Tyson A Fricke
- Royal Children's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | | | - Elie Sawan
- Royal Children's Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Royal Children's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Christian P Brizard
- Royal Children's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
| | - Igor E Konstantinov
- Royal Children's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Australia
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31
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Herrin MA, Zurakowski D, Fynn-Thompson F, Baird CW, del Nido PJ, Emani SM. Outcomes following thoracotomy or thoracoscopic vascular ring division in children and young adults. J Thorac Cardiovasc Surg 2017; 154:607-615. [DOI: 10.1016/j.jtcvs.2017.01.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 12/29/2016] [Accepted: 01/28/2017] [Indexed: 11/24/2022]
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32
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Mayer J, van der Werf-Grohmann N, Kroll J, Spiekerkoetter U, Stiller B, Grohmann J. Dysphagia after arteria lusoria dextra surgery: Anatomical considerations before redo-surgery. World J Cardiol 2017; 9:191-195. [PMID: 28289534 PMCID: PMC5329747 DOI: 10.4330/wjc.v9.i2.191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/28/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Aberrant right subclavian artery (arteria lusoria) is the most common congenital root anomaly, remaining asymptomatic in most cases. Nevertheless, some of the 20%-40% of those affected present tracheo-esophageal symptoms. We report on a 6-year-old previously healthy girl presenting with progressive dysphagia over 4 wk. Diagnostics including barium swallow, echocardiography and magnetic resonance angiography (MRA) revealed a retro-esophageal compression by an aberrant right subclavian artery. Despite the successful, uneventful transposition of this arteria lusoria to the right common carotid via right-sided thoracotomy, the girl was suffering from persisting dysphagia. Another barium swallow showed the persistent compression of the esophagus on the level where the arteria lusoria had originated. As MRA showed no evidence of a significant re-obstruction by the transected vascular stump, we suspected a persisting ligamentum arteriosum. After a second surgical intervention via left-sided thoracotomy consisting of transecting the obviously persisting ligamentum and shortening the remaining arterial stump of the aberrant right subclavian artery, the patient recovered fully. In this case report we discuss the potential relevance of a persisting ligamentum arteriosum for patients with left aortic arch suffering from dysphagia lusoria and rational means of diagnosing, as well as the surgical options to prevent re-do surgery.
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Tomografía computarizada con multidetectores en las anomalías congénitas del arco aórtico: anillos vasculares. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Matsushima S, Oshima Y, Matsuhisa H. Aortic arch reconstruction using a Kommerell diverticulum for hypoplastic left heart syndrome with a right aortic arch. J Thorac Cardiovasc Surg 2016; 152:e35-7. [DOI: 10.1016/j.jtcvs.2016.01.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 01/20/2016] [Accepted: 01/27/2016] [Indexed: 11/29/2022]
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García-Guereta L, García-Cerro E, Bret-Zurita M. Multidetector Computed Tomography for Congenital Anomalies of the Aortic Arch: Vascular Rings. ACTA ACUST UNITED AC 2016; 69:681-93. [PMID: 27311384 DOI: 10.1016/j.rec.2016.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/31/2016] [Indexed: 11/25/2022]
Abstract
The development of multidetector computed tomography has triggered a revolution in the study of the aorta and other large vessels and has replaced angiography in the diagnosis of congenital anomalies of the aortic arch, particularly vascular rings. The major advantage of multidetector computed tomography is that it permits clear 3-dimensional assessment of not only vascular structures, but also airway and esophageal compression. The current update aims to summarize the embryonic development of the aortic arch and the developmental anomalies leading to vascular ring formation and to discuss the current diagnostic and therapeutic role of multidetector computed tomography in this field.
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Affiliation(s)
- Luis García-Guereta
- Servicio de Cardiología Pediátrica, Hospital Universitario La Paz, Madrid, Spain.
| | | | - Montserrat Bret-Zurita
- Servicio de Radiodiagnóstico, Radiología Pediátrica, Imagen Cardiaca Pediátrica y Cardiopatías Congénitas, Hospital Universitario La Paz, Madrid, Spain
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Abstract
The term vascular ring refers to congenital vascular anomalies of the aortic arch system that compress the esophagus and trachea, causing symptoms related to those two structures. The most common vascular rings are double aortic arch and right aortic arch with left ligamentum. Pulmonary artery sling is rare and these patients need to be carefully evaluated for frequently associated tracheal stenosis. Another cause of tracheal compression occurring only in infants is the innominate artery compression syndrome. In the current era, the diagnosis of a vascular ring is best established by CT imaging that can accurately delineate the anatomy of the vascular ring and associated tracheal pathology. For patients with a right aortic arch there recently has been an increased recognition of a structure called a Kommerell diverticulum which may require resection and transfer of the left subclavian artery to the left carotid artery. A very rare vascular ring is the circumflex aorta that is now treated with the aortic uncrossing operation. Patients with vascular rings should all have an echocardiogram because of the incidence of associated congenital heart disease. We also recommend bronchoscopy to assess for additional tracheal pathology and provide an assessment of the degree of tracheomalacia and bronchomalacia. The outcomes of surgical intervention are excellent and most patients have complete resolution of symptoms over a period of time.
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Affiliation(s)
- Carl L Backer
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 22, 225 E. Chicago Ave, Chicago, Illinois 60611; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Michael C Mongé
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 22, 225 E. Chicago Ave, Chicago, Illinois 60611; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrada R Popescu
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Osama M Eltayeb
- Division of Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 22, 225 E. Chicago Ave, Chicago, Illinois 60611; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey C Rastatter
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Otolaryngology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sánchez Pérez R, Rey Lois J, Polo López L, Aroca Peinado Á, González Rocafort Á, Pérez González R, Deiros Bronte L, Bret Zurita M, García-Guereta Silva L, Diez Sebastián J, Villagrá Blanco F. Anillos vasculares y compresión traqueo-esofágica: 15 años de experiencia quirúrgica. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Honjo O. Is native tissue always better? J Thorac Cardiovasc Surg 2016; 152:e39-40. [PMID: 27050554 DOI: 10.1016/j.jtcvs.2016.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Osami Honjo
- Division of Cardiovascular Surgery, Department of Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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