Video-assisted Thoracoscopic Surgery: Is It a Superior Technique for the Division of Vascular Rings in Children?

Perioperative and Anesthetic Considerations in Vascular Rings and Slings

Vascular rings represent an increasingly prevalent and diverse set of congenital malformations in which the aortic arch and its primary branches encircle and constrict the esophagus and trachea. Perioperative management varies significantly based on the type of lesion, its associated comorbidities, and the compromise of adjacent structures. Multiple review articles have been published describing the scope of vascular rings and relevant concerns from a surgical perspective. This review seeks to discuss the perioperative implications and recommendations of such pathology from the perspective of an anesthesia provider.

Long-term Outcomes Following Thoracoscopic Division of Vascular Rings

OBJECTIVES

We evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center.

METHODS

All pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007-12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews.

RESULTS

60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time.

CONCLUSION

Division of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings.

LEVEL OF EVIDENCE

Level IV.

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.

Vascular rings

Vascular rings are congenital aortic arch anomalies that lead to compression of the trachea or esophagus. The goal of this review is to summarize our current recommendations for the management of patients with a diagnosis of a vascular ring. We review the history, classification methods, and epidemiology of the various types of vascular rings. We then propose a management strategy for the relatively new paradigm of fetal diagnosis, including the management of asymptomatic vascular rings. Finally, we finish with a review of the operative techniques and outcomes for the four main categories of vascular rings.

Ligation of the ligamentum arteriosum and aberrant left subclavian artery in five dogs in which persistent right aortic arch had been diagnosed

OBJECTIVE

To determine and report the diagnosis, treatment, and outcome in dogs with persistent right aortic arch (PRAA) with an aberrant left subclavian artery (ALS) that underwent thoracoscopic surgery.

ANIMALS

Dogs with PRAA and an ALS (n = 5).

STUDY DESIGN

Short case series.

METHODS

Medical records were reviewed from 2014 to 2019. Dogs that underwent thoracoscopy for PRAA with an ALS at an academic referral hospital were included. Signalment, clinical signs, diagnostic imaging, surgical approach, complications, and short- and long-term outcomes were recorded.

RESULTS

Persistent right aortic arch with an ALS was identified in five dogs. Dogs initially underwent a three-port intercostal thoracoscopic approach, and an intercostal thoracotomy was performed in converted cases. In all five dogs, the ligamentum arteriosum (LA) and ALS were divided; three were performed by a thoracoscopy alone. Two cases were converted because of poor exposure (1) and requirement to temporary occlude an ALS (1). The ALS was ligated and divided in all dogs without apparent negative effects. No intraoperative or postoperative complications occurred. Four dogs had resolution of regurgitation, three of which required diet modification. One dog had reported regurgitation when it was excited. Median follow-up was 188 days (range, 150-1133).

CONCLUSION

Ligation and division of both the LA and the ALS in all dogs in this case series was safe and allowed for improvement in clinical signs and good to excellent long-term outcomes. In addition, both thoracoscopy and thoracotomy were used safely and successfully for ligation and transection of the LA and ALS in all dogs.

Borrowing from Adult Cardiac Surgeons-Bringing Congenital Heart Surgery Up to Speed in the Minimally Invasive Era

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.

Official American Thoracic Society Clinical Practice Guidelines: Diagnostic Evaluation of Infants with Recurrent or Persistent Wheezing

BACKGROUND

Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies.

METHODS

An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations.

RESULTS

The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolar lavage, esophageal pH monitoring, and a swallowing study. It also made conditional recommendations against empiric food avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles of infant pulmonary function testing and food avoidance or dietary changes, based on allergy testing.

CONCLUSIONS

Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence.

Thoracoscopic division of vascular rings

BACKGROUND/PURPOSE

Vascular rings are traditionally treated via an open thoracotomy. In recent years the use of thoracoscopy has increased. Herein we report our experience with thoracoscopic division of vascular rings in pediatric patients.

METHODS

We reviewed all patients who underwent thoracoscopic or open division of a vascular ring at our institution between 2007 and 2015. We analyzed patient demographics, presenting symptoms, diagnostic imaging modality, ring anatomy, operative details, complications, and symptom resolution.

RESULTS

Thirty-one patients underwent thoracoscopic division of a vascular ring while sixteen had open operations. Median age was 24months in the thoracoscopic group and 13months in the open group. Operative time averaged 74min (thoracoscopic) and 95min (open). There were no mortalities at 30days. There was complete symptom resolution in 71% of thoracoscopic patients and 63% of open. Patients in the thoracoscopic group had decreased ICU admissions (10% vs. 94%), chest tube use (62% vs. 100%), chylothorax (6% vs. 38%) and overall length of stay (1.7days vs. 5days).

CONCLUSIONS

Thoracoscopic division of vascular rings in pediatric patients is a feasible alternative to open division and is associated with comparable rates of symptom resolution and decreased length of hospital stay and chylothorax.

LEVEL OF EVIDENCE

III.

Multidetector Computed Tomography for Congenital Anomalies of the Aortic Arch: Vascular Rings

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.

Vascular rings

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.

Congenital vascular rings: a clinical challenge for the pediatrician

Vascular rings are congenital anomalies that lead to variable degrees of respiratory problems or feeding difficulties by forming a complete or partial ring compressing the trachea, the bronchi, and the esophagus. The clinical diagnosis of vascular rings is often challenging for the pediatrician because the clinical manifestations are heterogeneous and nonspecific. Symptoms can vary from wheezing, stridor, dyspnea, and/or dysphagia to life-threatening conditions; however, they may not be present. The aim of this study is to review the recent literature on this subject and describe new developments in diagnostics and imaging.

Video-assisted thoracoscopic division of vascular rings

This study reports our early experience with thoracoscopic division of vascular rings. Three patients were reviewed; their ages at surgery were 25 months, 4 years, and 57 years. All patients were suffering from complete vascular rings involving combinations of the right aortic arch, left ligamentum arteriosum, Kommerell’s diverticulum, and retroesophageal left subclavian artery. The median surgical time was 180.5 minutes, and the patients showed immediate recovery. Three complications, namely chylothorax, transient supraventricular tachycardia, and left vocal cord palsy, were observed. Our early experience indicates that thoracoscopic division of a vascular ring may provide early recovery and could be a promising operative choice.

Video assisted thoracoscopic surgery cases with right-sided aortic arch aneurysm and complete vascular ring: Case report

•

Think of vascular ring when facing an infant with vomiting after feeding, stridor, high pitched and brassy cough, noisy respiration, emesis and respiratory distress.

•

Use of CT angiography, MRI and barium swallow to evaluate vascular ring and its type.

•

Video assisted thoracoscopic surgery (VATS) is a feasible procedure for sectioning the right-sided aortic arch by the use of clips.

Introduction

Right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum, after double aortic arch, is the second most common complete vascular ring. It was traditionally treated by open surgical thoracotomy and recently video assisted thoracoscopic surgery (VATS) has been used in some cases.

Presentation of case

We describe the cases of two infants who presented with gastroesophageal reflux, dyspnea, dysphagia secondary to aneurysmal dilatation of the retroesophageal arch confirmed by imaging data. VATS procedure was performed through a left thoracoscopic approach. Ligamentum arteriosus compressed esophagus was clipped, sectioned and then released the esophagus in one case; also, In the second case, we clipped and sectioned aorta, distal to the origin of aberrant left subclavian artery.

Discussion

CT angiography and MRI are known to be the most effective available imaging methods for vascular ring detection. Also, there are several surgical approaches to vascular rings such as, thoracotomy and thoracoscopy. There is a large body of evidence confirming the safety, efficacy and convenience of VATS as a therapeutic option for congenital heart disease including right-sided aortic arch and aberrant left subclavian artery.

Conclusion

VATS is a less invasive and safe strategy for management of right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum.

Paediatric thoracoscopic surgery

Thoracoscopic surgery is now an integral part of paediatric practice. The evolution of instrumentation, optics and haemostatic devices have enabled even the most complex procedures to be carried out thoracoscopically. Although randomised studies are limited in children, thoracoscopic surgery appears to offer outcomes at least equivalent to that of open operations with less post-operative pain, less scarring and a more rapid recovery. Furthermore many of the long term musculo-skeletal deformities associated with a thoracotomy are avoided. There are however several surgical and anaesthetic challenges that make the widespread application of these techniques beyond that of specialised centres difficult.