Original article: cardiovascular
Vascular anomalies and tracheoesophageal compression: a single institution’s 25-year experience

https://doi.org/10.1016/S0003-4975(01)02806-5Get rights and content

Abstract

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

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

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

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

Section snippets

Patients and methods

We retrospectively reviewed the charts of 82 patients with symptomatic compression of the trachea or esophagus secondary to anomalies of the aortic arch and great vessels, diagnosed from 1974 to 2000. Age at the time of operation ranged from 2 weeks to 12 years (mean, 1.7 years). The male to female ratio was 2 to 1. The number of patients presenting per decade was 17 in the 1970s, 21 in the 1980s, and 44 in the 1990s.

Types of vascular anomalies

Patients were categorized according to six types of vascular anomalies: (1) double aortic arch (31 patients); (2) right arch left ligamentum (22 patients); (3) innominate artery compression (20 patients); (4) aberrant right subclavian artery (4 patients); (5) pulmonary artery sling (3 patients); and (6) aberrant left subclavian artery (2 patients). Out of those patients with double aortic arch, right dominance occurred in 25 patients (81%), left dominance in 5 patients (16%), and codominance in

Comment

Gross and Ware [10] defined the operative repair of double aortic arch in 1945 and the surgical management of other vascular anomalies in 1946, indicating the utility of left thoracotomy for division of the ring or symptomatic vessel. In that same year, Neuhauser [11] described the radiographic criteria for diagnosing the various types of anomalies, based on the chest radiograph and the barium swallow. (For a complete description of these criteria, please see Neuhauser’s article.) In summary,

References (23)

  • I.L Hartyanszky et al.

    Congenital vascular ringssurgical management of 111 cases

    Eur J Cardiothorac Surg

    (1989)
  • Cited by (139)

    • Great vessel anomalies and their impact on the surgical treatment of tracheobronchomalacia

      2020, Journal of Pediatric Surgery
      Citation Excerpt :

      An anterior approach facilitates arch reconstruction or aortic uncrossing procedures, repair of pulmonary artery sling, ductal ligament division, as well as providing access for repair of structural congenital heart defects. [18] This anterior approach through a median sternotomy also is used to anteriorly move and directly support the ascending aorta, innominate artery, pulmonary artery, the trachea, and the bilateral mainstem bronchi. [20,23,24] As the malformed tracheal rings will often maintain their abnormal restrictive shape after vascular elevation, a direct tracheobronchopexy to the sternum or anterior structures of the neck is often required to open the airways.

    View all citing articles on Scopus
    View full text