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Zhao J, Zhang Y, Zhang L. A child with congenital double aortic arch: Reflections on the surgical approach and timing. Asian J Surg 2024; 47:2683-2684. [PMID: 38522995 DOI: 10.1016/j.asjsur.2024.03.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Jinliang Zhao
- Department of Pediatric Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Yan Zhang
- Department of Orthopaedic, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Libing Zhang
- Department of Pediatric Surgery, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China.
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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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Evaluation of the trachea in fetuses with double aortic arch using prenatal ultrasound: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:100759. [PMID: 36191891 DOI: 10.1016/j.ajogmf.2022.100759] [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: 08/03/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Double aortic arch is the most common form of complete vascular ring. The trachea and/or esophagus could be compressed by the complete vascular ring, which may lead to early respiratory and/or esophageal symptoms in children with double aortic arch. Accurate prenatal assessment of tracheal compression could provide relevant information for perinatal clinical management of double aortic arch and emergency treatment of infants with double aortic arch. The fetal trachea is filled with amniotic fluid and can be clearly visualized with prenatal ultrasound. Previous studies reported the use of prenatal ultrasound to measure the tracheal internal diameters in normal fetuses and showed a linear correlation between the fetal tracheal internal diameters and gestational age. However, to the best of our knowledge, few studies have quantitatively evaluated tracheal compression in fetuses with double aortic arch using ultrasound. OBJECTIVE This study aimed to evaluate the tracheal compression caused by the vascular ring in fetuses with double aortic arch using prenatal ultrasound and to analyze the relationship between tracheal compression and postnatal clinical symptoms. STUDY DESIGN The data of fetuses with double aortic arch diagnosed with prenatal ultrasound at 2 institutions from January 2011 to April 2021 were retrospectively analyzed. Singleton pregnancies with normal fetuses as the control group were prospectively recruited. The tracheal compression-evaluated by comparing the tracheal internal diameter z scores against the gestational age-was assessed in fetuses with double aortic arch and in normal fetuses. The live-born infants with double aortic arch were divided into symptomatic and asymptomatic groups for the comparison of z scores. The receiver operating characteristic curve for the tracheal internal diameter z score cutoffs and prediction of symptomatic infants with double aortic arch was plotted. Intraobserver and interobserver agreements were investigated. RESULTS A total of 26 fetuses with double aortic arch were diagnosed, and 14 fetuses (53.8%) with double aortic arch were delivered alive. Among the 14 live-born infants, 7 (50.0%) were symptomatic, whereas 7 (50.0%) were asymptomatic. The tracheal internal diameter z scores were significantly lower in the double aortic arch group than in the normal groups (-0.62±1.36 vs 0.00±0.78; P<.001). The tracheal internal diameter z scores were significantly lower in the symptomatic group than in the asymptomatic group (-1.42±0.92 vs -0.49±0.96; P=.018). The area under the curve was 0.878 (95% confidence interval, 0.689-1.000). Using a tracheal internal diameter z scores cutoff of -1.21, the sensitivity was 71%, and the specificity was close to 100%. The intraclass correlation coefficients of interobserver and intraobserver agreements were 0.987 (95% confidence interval, 0.980-0.992) and 0.975 (95% confidence interval, 0.955-0.987), respectively. CONCLUSION The clinical symptoms in infants with double aortic arch were associated with prenatal tracheal compression, which can be prenatally evaluated using ultrasound. If fetuses are diagnosed with double aortic arch, prenatal surveillance of the tracheal internal diameters and comparison with z score reference ranges could provide pertinent information that would aid perinatal clinical management.
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Avnioglu S, Dikici R, Etli M. 3D modeling and comparative analysis of the double arcus aorta case. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:2263-2268. [PMID: 37726466 DOI: 10.1007/s10554-022-02675-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/05/2022]
Abstract
We analyzed the double arch of a 51-year-old male patient who applied to the outpatient clinic with chest pain and shortness of breath and compared this rare case with the studies in the literature. Double aortic arch (DAA) is defined as a type of vascular ring malformation. The incidence of congenital heart diseases is less than 1%. DAA makes up 46-76% of all rings. We aimed to contribute to cardiac surgery by examining and modeling the diameters in the 2D and 3D images of the patient. For 3D modeling, an open-source software program ITK-SNAP 3.8 was used, which converts 2D images from MRI, CT, and ultrasound to 3D medical image volumes. CT images of the case taken from the SECTRA system of our hospital were uploaded to ITK-SNAP and segmentation was performed. With 3D modeling, a better understanding of the stenosis in the trachea and the double arch was achieved. The ascending aorta diameter was 30 mm. There were atherosclerotic changes in the aorta and its branches. The diameter of the right aortic arch was 22.2 mm, and the diameter of the left aortic arch was 14.5 mm. Trachea diameter was found to be 17 mm/13.2 mm. Esophageal diameter was 9.8 mm. The patient had no specific complaints and no medical or surgical treatment was recommended because his physical examination was normal. We think that a better understanding of such cases in 3D may contribute to cardiovascular surgery.
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Affiliation(s)
- Seda Avnioglu
- Department of Anatomy, Faculty of Medicine, Alanya Alaaddin Keykubat University, Antalya, Turkey
| | - Rumeysa Dikici
- Department of Anatomy, Faculty of Medicine, Alanya Alaaddin Keykubat University, Antalya, Turkey.
| | - Mustafa Etli
- Department of Cardiovascular Surgery, Faculty of Medicine, Alanya Alaaddin Keykubat University, Antalya, Turkey
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Ling Y, Schenkel T, Tang J, Liu H. Computational fluid dynamics investigation on aortic hemodynamics in double aortic arch before and after ligation surgery. J Biomech 2022; 141:111231. [PMID: 35901663 DOI: 10.1016/j.jbiomech.2022.111231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 02/08/2023]
Abstract
Double aortic arch (DAA) malformation is one of the reasons for symptomatic vascular rings, the hemodynamics of which is still poorly understood. This study aims to investigate the blood flow characteristics in patient-specific double aortic arches using computational fluid dynamics (CFD). Seven cases of infantile patients with DAA were collected and their computed tomography images were used to reconstruct 3D computational models. A modified Carreau model was used to consider the non-Newtonian effect of blood and a three-element Windkessel model taking the effect of the age of patients into account was applied to reproduce physiological pressure waveforms. Numerical results show that blood flow distribution and energy loss of DAA depends on relative sizes of the two aortic arches and their angles with the ascending aorta. Ligation of either aortic arch increases the energy loss of blood in the DAA, leading to the increase in cardiac workload. Generally, the rising rate of energy loss before and after the surgery is almost linear with the area ratio between the aortic arch without ligation and the ascending aorta.
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Affiliation(s)
- Yunfei Ling
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu 610041, China; State Key Laboratory of Hydraulics and Mountain River Engineering, College of Water Resource & Hydropower, Sichuan University, Chengdu 610065, China
| | - Torsten Schenkel
- Department of Engineering and Mathematics, Sheffield Hallam University, Sheffield S1 1WB, United Kingdom
| | - Jiguo Tang
- State Key Laboratory of Hydraulics and Mountain River Engineering, College of Water Resource & Hydropower, Sichuan University, Chengdu 610065, China.
| | - Hongtao Liu
- State Key Laboratory of Hydraulics and Mountain River Engineering, College of Water Resource & Hydropower, Sichuan University, Chengdu 610065, China
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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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Bae SB, Kang EJ, Choo KS, Lee J, Kim SH, Lim KJ, Kwon H. Aortic Arch Variants and Anomalies: Embryology, Imaging Findings, and Clinical Considerations. J Cardiovasc Imaging 2022; 30:231-262. [PMID: 36280266 PMCID: PMC9592245 DOI: 10.4250/jcvi.2022.0058] [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: 05/06/2022] [Revised: 07/15/2022] [Accepted: 07/17/2022] [Indexed: 11/22/2022] Open
Abstract
There is a wide spectrum of congenital anomalies or variations of the aortic arch, ranging from non-symptomatic variations that are mostly detected incidentally to clinically symptomatic variations that cause severe respiratory distress or esophageal compression. Some of these may be accompanied by other congenital heart diseases or chromosomal anomalies. The widespread use of multidetector computed tomography (CT) in clinical practice has resulted in incidental detection of several variations of the aortic arch in adults. Thus, radiologists and clinicians should be aware of the classification of aortic arch anomalies and carefully look for imaging features associated with a high risk of clinical symptoms. Understanding the embryological development of the aortic arch aids in the classification of various subtypes of aortic arch anomalies and variants. For accurate diagnosis and precise evaluation of aortic arch anomalies, cross-sectional imaging modalities, such as multidetector CT or magnetic resonance imaging, play an important role by providing three-dimensional reconstructed images. In this review, we describe the embryological development of the thoracic aorta and discuss variations and anomalies of the aortic arch along with their clinical implications.
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Affiliation(s)
- Sang Bin Bae
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea
| | - Eun-Ju Kang
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jongmin Lee
- Department of Radiology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sang Hyeon Kim
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea
| | - Kyoung Jae Lim
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea
| | - Heejin Kwon
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea
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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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Priya S, Nagpal P. Atretic Double Aortic Arch: Imaging Appearance of a Rare Anomaly and Differentiation From Its Mimics. Cureus 2020; 12:e9478. [PMID: 32884866 PMCID: PMC7461656 DOI: 10.7759/cureus.9478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
A double aortic arch (DAA) with atresia is an uncommon cause of a symptomatic vascular ring resulting in trachea-esophageal compression. An atretic double aortic arch can resemble the right aortic arch with a mirror image branching pattern or the right arch with an aberrant left subclavian artery depending upon the level of atresia. The double aortic arch with atresia is difficult to detect on pre-surgical computed tomography angiography or magnetic resonance angiography due to a lack of contrast in the obliterated arch segment. Differentiation of a double arch with atresia from the right aortic arch is vital as an atretic double arch is a form of the complete vascular ring while the right aortic arch may or may not be symptomatic. Knowledge of some key imaging features can help distinguish these entities. In this case report, we discuss an uncommon case of a double aortic arch with atresia between the left common carotid and left subclavian artery. We also describe its close mimics, their embryological basis, and ways to differentiate it from the right aortic arch.
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Affiliation(s)
- Sarv Priya
- Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
| | - Prashant Nagpal
- Cardiothoracic Radiology, University of Iowa Hospitals and Clinics, Iowa City, USA
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Dixon CM, Dyar D, Aurigemma D, Printz BF, Hegde S, Ryan J, Loo JC, Sun HY. Double Choker: Double Aortic Arch with Bilateral Aortic Coarctation Associated with Heterotaxy-Asplenia Syndrome and Complex Atrioventricular Canal Defect. CASE (PHILADELPHIA, PA.) 2020; 4:142-145. [PMID: 32577594 PMCID: PMC7303239 DOI: 10.1016/j.case.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
• Double aortic arch (DAA) typically occurs in isolation. • DAA with bilateral coarctation (COA) is very rare with three prior documented cases. • In addition to DAA with bilateral COA our case also has complex intracardiac disease. • Echocardiography served as the primary diagnostic tool with advanced imaging as a useful adjunct.
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Affiliation(s)
- Chandler M Dixon
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
| | - Dan Dyar
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
| | - David Aurigemma
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
- Division of Cardiology, Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Beth F Printz
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
- Division of Cardiology, Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Sanjeet Hegde
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
- Division of Cardiology, Department of Pediatrics, University of California, San Diego, San Diego, California
| | - Justin Ryan
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
| | - John-Charles Loo
- Division of Cardiology, Department of Pediatrics, Kaiser Permanente, Tustin, California
| | - Heather Y Sun
- Division of Cardiology, Rady Children's Hospital San Diego, San Diego, California
- Division of Cardiology, Department of Pediatrics, University of California, San Diego, San Diego, California
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