Repair of a Complete Vascular Ring in a 2-Month-Old

The authors present the surgical repair of a complete vascular ring consisting of a double aortic arch in a 2-month-old boy who presented with noisy breathing and difficulty swallowing. Diagnosis was confirmed with a computed tomography scan, which showed a complete vascular ring consisting of a dominant right aortic arch and partially atretic left arch. The atretic segment was located between the left subclavian artery and the ductus diverticulum.

After induction of general endotracheal anesthesia, a paravertebral catheter was placed for postoperative pain management, in addition to placement of the necessary monitoring lines including cerebral and somatic near infrared spectroscopy (NIRS), left radial, and a femoral arterial line. In other terms, all four extremities were routinely monitored. The patient was positioned in the right lateral decubitus position. The left chest was entered through the left third intercostal space. The left lung was retracted medially, and the mediastinal pleura was opened on top of the esophagus and left subclavian artery. The authors take considerable time to identify all components of the vascular ring, which in this case were the left subclavian artery, right and left aortic arches, and ductus arteriosus. All arch vessels were visualized and dissected.

The atretic portion of the left aortic arch was doubly clipped and divided, which released the esophagus partially. The ductus arteriosus was dissected and a medium size hemoclip was applied at its pulmonary end while a side-biting clamp was placed at its aortic end. The ductus and its diverticulum were divided and the aortic end was secured with a running double layer of 5/0 polypropylene suture. This transforms the double aortic arch into a right arch with mirror-image branching in other terms. The esophagus was completely mobilized and all crossing muscle fibers were divided. The authors do not close the mediastinal pleura in these cases to avoid recurrence of scarring with the possibility of recurrence of symptoms. A single chest tube was placed and the incision was closed in the standard fashion. The patient was extubated in the operating room, received no transfusions, and the rest of the hospital course was uneventful. He was discharged on the third postoperative day.

References

1. Backer CL. Vascular rings with tracheoesophageal compression: management considerations. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2020;23:48-52.
2. Backer CL, Mongé MC, Popescu AR, Eltayeb OM, Rastatter JC, Rigsby CK. Vascular rings. Semin Pediatr Surg. 2016 Jun;25(3):165-175.
3. Backer CL, Bharadwaj SN, Eltayeb OM, Forbess JM, Popescu AR, Mongé MC. Double aortic arch with Kommerell diverticulum. Ann Thorac Surg. 2019 Jul;108(1):161-166.

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