Thoracoscopic Repair of a Double Aortic Arch

Introduction

Double aortic arch is a relatively rare cardiovascular malformation. It is an anomaly of the aortic arch in which two aortic arches form a complete vascular ring that can compress the trachea and/or esophagus.

Case Report

The patient was a 13-year-old, 77 kilogram girl with solid dysphagia. The CT scan revealed a double aortic arch that caused compression of the esophagus but not of the airway. The left aortic arch was the smaller.

Operation Technique and Result

The patient was placed in a right lateral decubitus position. Two 3 millimetre and two 5 millimetre trocars were inserted. A 5 millimetre 30-degree angle camera was advanced and C02 was insufflated until lung collapse was achieved. It is also helpful to use a left bronchus blocker.

The mediastinal pleura was opened from the left subclavian artery to the descending aorta. The crossing vein was dissected and divided with Ligasure Maryland (Medtronic Ligasure Tm Maryland Jaw Thoracic Sealer-Divider). The ligamentum arteriosum was dissected and controlled with a vessel loop with special caution of the left recurrent laryngeal nerve. The ligamentum was ligated with four hem-o-lok clips (Teleflex Medical Weck Closure System). It was cut leaving two clips on each side.

The left aortic dissection is continued. Two vessel loops are passed around it. A 30 millimetre vascular Endo Gia (tri-Staple TM 30 mm Endo Gia TM Covidien) was advanced after removing a 5 millimetre trocar. The left aortic arch was occluded between the two marks of the stapler and it was cut.

Adhesive bands surrounding the esophagus and trachea were dissected and divided. A chest tube was placed. The mediastinal pleura was left widely open. Closure was performed with absorbable sutures.

The patient was extubated in the OR. Chest tube was removed in the first 24 hours. Intensive care unit stay was one day. The postoperative course was uneventful. The patient was discharged home six days after surgery. After one year of follow-up, the patient remains asymptomatic.

References

1. Koontz CS, Bhatia A, Forbess J, Wulkan ML. Video-assisted thoracoscopic division of vascular rings in pediatric patients. Am Surg. 2005;71(4):289-291.
2. Suematsu Y, Mora BN, Mihaljevic T, Del Nido P. Totally endoscopic robotic-assisted repair of patent ductus arteriosus and vascular ring in children. Ann Thorac Surg. 2005;80(6):2309-2313.
3. Slater B, Rothenberg SS. Thoracoscopic management of patent ductus arteriosus and vascular rings in infants and children. J Laparoendosc Adv Surg Tech A. 2016;26(1):66-69.

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