Vascular ring

Provided by "Pediatric Heart Surgery — a reference for professionals"

Pathophysiology

Vascular ring is an anomaly of aortic arch development in which the trachea and esophagus are completely encircled by vascular structures. The most common types of vascular ring involve a dominant right aortic arch with a persistent left ductus arteriosus or ligamentum arteriosus. Double aortic arch, as the name implies, occurs when there are two aortic arches. The posterior, right aortic arch gives rise to the right common carotid artery and the right subclavian artery. The anterior, left aortic arch gives rise to the left common carotid artery and the left subclavian artery. Double aortic arch encircles the trachea and the esophagus and can cause compression of either structure. Traditionally, a barium swallow study was performed to aid in diagnosis. More recently, advanced imaging techniques such as echocardiography, CT, and MRI are commonly used.

Surgical technique

Repair of double aortic arch is performed through a left thoracotomy. Cardiopulmonary bypass is not required for repair of this anomaly. The aortic arch anatomy is first identified. The non-dominant aortic arch is divided and oversewn, taking care to avoid compromise of blood flow to the branches arising from the aortic arches. The ligamentum arteriosus is divided in all cases. Many surgeons perform aortopexy, with anterior suspension of the left aortic arch segment to the posterior aspect of the sternum.

Postoperative considerations

The postoperative course following repair of double aortic arch type vascular ring is usually benign. Invasive monitors used include an arterial catheter and rarely, a central venous catheter. Vasoactive infusions are rarely required for postoperative hemodynamic management. Phrenic nerve or recurrent laryngeal nerve injury is rarely encountered. Bleeding is an uncommon postoperative complication. Tracheomalacia may coexist and can cause respiratory symptoms. Length of hospital stay required following repair of double aortic arch aver- ages 3 to 6 days.