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Asian Cardiovasc Thorac Ann 1998;6:147-148
© 1998 Asia Publishing EXchange Pte Ltd

LETTER TO THE EDITOR

Extrapleural Approach for Interruption of Double Aortic Arch to Relieve Vascular Ring

Hemant Pramod Pathare, MS, Reshma Manoj Biniwale, MS, Namrata Gaur, MS, Sanjay Basavaraj Dhaded, MCh, Jagdish Khandeparkar, MCh, Ratna A Magotra, MS

Dept. of Cardiovascular & Thoracic Surgery King Edward VII Memorial Hospital Parel Bombay 400012, India
Vascular ring syndrome describes abnormalities of the aortic arch that result in complete or partial encirclement of the trachea or esophagus with resultant dysphagia and dyspnea.1 We describe the case of a 6-month-old female who underwent repair of such an anomaly by an extrapleural approach. The infant presented with stridor, recurrent respiratory tract infections, dysphagia, and failure to thrive since birth. Radiography demonstrated a right-sided aortic arch. Arterial blood gas analysis revealed persistent hypoxia and acidosis. Transthoracic ultrasound suggested tracheoesophageal compressive syndrome.2 Barium swallow showed a posterior indentation of the esophagus at T4 level. A computerized tomographic angiogram showed a double aortic arch with a right descending thoracic aorta (Figure 1Go).



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  		Figure 1. Computerized tomogram with contrast angiography showing a double aortic arch with right descending thoracic aorta.

 
At surgery, we adopted an extrapleural approach via a right posterolateral thoracotomy incision.3 The entire right pleura was mobilized anteriorly and posteriorly up to the hilum and the apex was freed. The anterior and posterior aortic arches and the descending thoracic aorta were dissected and looped with umbilical tapes. Temporary occlusion of the anterior aortic arch revealed interruption of flow in the descending thoracic aorta, whereas when the posterior aortic arch was occluded temporarily, distal pulsatile flow was maintained. The posterior aortic arch was divided proximal to the left common carotid artery and both ends were over-sewn with 6/0 polypropylene suture. There was no ductus arteriosus. The chest was closed without drainage. The postoperative brachial artery pressure was identical in both upper limbs. The child had an uneventful convalescence.

Double aortic arch is one of the causes of the rare vascular ring syndrome.1 Usually the posterior aortic arch is dominant. In our patient, the anterior aortic arch was dominant because pulsatile flow in the descending thoracic aorta was maintained during temporary occlusion of the posterior arch, whereas occlusion of the anterior arch abolished pulsatile flow. Such patients present with compromised pulmonary function due to recurrent lower respiratory infection. In addition, there is always the possibility of aspiration due to compression of the esophagus. Using the described approach, the pleural cavity was not violated and there was no need for intercostal drainage and its attendant morbidity. By maintaining negative intrapleural pressure, the chances of collapse and effusion are reduced. The extrapleural approach is advantageous in younger children because the pleura can be separated from the parietes with ease. We employ an extrapleural approach routinely for interruption of patent ductus arteriosus in suitable cases. We have found that even small pleural rents do not require intercostal drainage. Furthermore, adopting an extrapleural approach for such children helps in preserving their already compromised pulmonary function. This case is reported to highlight the fact that dyspnea or dysphagia in infants may occasionally be due to such rare conditions.

REFERENCES

  1. Mainwaring RD, Lamberti JJ. Tracheoesophageal compressive syndromes. In: Baue A, Geha AS, Hammond GL, Laks H, Naunheim KS, editors. Glenn's thoracic and cardiovascular surgery. 6th ed. Stamford: Appleton & Lange 1996;65:1095–103.

  2. Lillehei CW, Colan S. Echocardiography in preoperative evaluation of vascular rings. J Pediatr Surg 1992;27:1118–21.[Medline]

  3. McFaul R, Millard P, Nowicki E. Vascular rings necessitating right thoracotomy. J Thorac Cardiovasc Surg 1981; 82:306–9.[Medline]





This Article
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Ratna A Magotra
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Right arrow Articles by Magotra, R. A

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