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Seminars in Pediatric Surgery Dec 2021Vascular rings are congenital aortic arch anomalies that lead to compression of the trachea or esophagus. The goal of this review is to summarize our current... (Review)
Review
Vascular rings are congenital aortic arch anomalies that lead to compression of the trachea or esophagus. The goal of this review is to summarize our current recommendations for the management of patients with a diagnosis of a vascular ring. We review the history, classification methods, and epidemiology of the various types of vascular rings. We then propose a management strategy for the relatively new paradigm of fetal diagnosis, including the management of asymptomatic vascular rings. Finally, we finish with a review of the operative techniques and outcomes for the four main categories of vascular rings.
Topics: Aorta, Thoracic; Esophagus; Heart Defects, Congenital; Humans; Subclavian Artery; Vascular Ring
PubMed: 34930596
DOI: 10.1016/j.sempedsurg.2021.151128 -
Surgery Today Oct 2020A vascular ring is a rare congenital cardiovascular anomaly, which encircles and compresses the trachea or esophagus, or both. In this review we discuss the... (Review)
Review
A vascular ring is a rare congenital cardiovascular anomaly, which encircles and compresses the trachea or esophagus, or both. In this review we discuss the pathophysiology, theoretical embryopathogenesis, diagnostic modalities, and surgical treatment of the different types of vascular ring. Knowledge of the normal embryonic development of the aortic arch and related structures is important for understanding and classifying the various forms of vascular ring. The development of a vascular ring begins with the embryonic aortic arch system. The persistence, involution, or regression of the arches determines the multiple variations of vascular ring. With the development of new technologies, multi-detector computed tomography (MDCT) has become a good diagnostic modality for pre- and postoperative evaluation. MDCT provides an excellent image of aortic arch abnormalities and the related anatomy, as well as the tracheal pathology. For patients with symptoms, surgical division of the vascular ring usually achieves excellent outcomes with marked resolution of symptoms and a low risk of morbidity and mortality. Symptomatic vascular rings require early surgical intervention to prevent prolonged vascular compression of the airway and serious complications.
Topics: Aorta, Thoracic; Deglutition Disorders; Dyspnea; Humans; Multidetector Computed Tomography; Vascular Ring
PubMed: 31676999
DOI: 10.1007/s00595-019-01907-5 -
No Shinkei Geka. Neurological Surgery May 2024A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this... (Review)
Review
A right aortic arch and aberrant subclavian artery result from an interruption in the remodeling of the pharyngeal arch arteries. We occasionally encounter this anatomical variation during angiography. Patients with disorders such as Down syndrome and congenital heart disease show a high incidence of an aberrant right subclavian artery, and this anomaly can cause symptomatic esophageal or tracheal compression. The root of the aberrant artery may show dilatation(referred to as a Kommerell diverticulum), dissection, intramural hematoma, or rupture necessitating cardiac intervention using a surgical or endovascular approach. Neurointerventionalists should have working knowledge of the anatomy to rapidly understand the anatomy and ensure a safe procedure. A left transradial approach should be considered if prior knowledge of the aberrant subclavian anatomy is available.
Topics: Humans; Aorta, Thoracic; Subclavian Artery; Vascular Remodeling; Cardiovascular Abnormalities
PubMed: 38783489
DOI: 10.11477/mf.1436204939 -
Asian Cardiovascular & Thoracic Annals Feb 2022Vascular rings are aortic arch anomalies with a spectrum of manifestations ranging from asymptomatic lesions detected incidentally to an acute presentation secondary to... (Review)
Review
BACKGROUND
Vascular rings are aortic arch anomalies with a spectrum of manifestations ranging from asymptomatic lesions detected incidentally to an acute presentation secondary to tracheo-esophageal compression. Circumflex retro-esophageal aortic arch is an extreme form of true vascular ring. It remains an uncharted territory to many surgeons.
METHODS
A comprehensive search of peer reviewed journals was completed based on the key words, "Circumflex aorta," "Circumflex retro-esophageal aorta" and "circumflex arch" using Google scholar, Scholars Portal Journals and PubMed. The reference section for each article found was searched to obtain additional articles. Literature on the circumflex aorta was reviewed starting from the embryogenesis to the latest management strategies.
RESULTS
Right circumflex aorta is more prevalent compared to left circumflex aorta. It can occur in isolation or in association with other intracardiac lesions. Mainly presents in children, however reported in adults too. The presentation may vary from asymptomatic lesion to acute respiratory distress secondary to airway compression. Computerized tomography (CT) and magnetic resonance imaging (MRI) are important tools in delineating the vascular anatomy. Aortic uncrossing is the definitive procedure. However, the role of concomitant tracheobronchopexy is emerging. Native tissue-to-tissue anastomosis is commonly preferred, but cases of extra-anatomic grafts are reported.
CONCLUSION
Circumflex aorta is amenable to complete repair. Preoperative delineation of anatomy is important for successful surgical outcome. Division of the retro-esophageal segment is crucial in relieving the compressive symptoms. In addition, tracheobronchopexy is helpful in addressing residual tracheomalacia but this accounts for a high-risk surgery.
Topics: Adult; Aorta; Aorta, Thoracic; Child; Heart Defects, Congenital; Humans; Trachea; Treatment Outcome; Vascular Ring
PubMed: 33957784
DOI: 10.1177/02184923211015092 -
Interactive Cardiovascular and Thoracic... Nov 2022
Topics: Humans; Aorta, Thoracic; Thorax
PubMed: 36394267
DOI: 10.1093/icvts/ivac270 -
The Journal of Thoracic and... Feb 2024Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic... (Review)
Review
OBJECTIVE
Cross-sectional imaging allows identification of rare patients with a vascular ring and circumflex aorta. The key diagnostic feature is crossing of the transverse aortic arch from right to left posterior to the trachea and superior to the carina in a patient with a right aortic arch. We evaluated our patients who received an aortic uncrossing procedure.
METHODS
We reviewed all patients who underwent aortic uncrossing from 2002 to 2022. All patients received preoperative computed tomography imaging and bronchoscopy.
RESULTS
Eleven patients ranging in age from 1.5 to 10 years (median 4 years) underwent aortic uncrossing. Two patients had prior left ligamentum division, and 3 patients had prior left aortic arch division. All had significant clinical symptoms. Eight patients had deep hypothermic circulatory arrest (mean 34 minutes), and 3 patients had antegrade cerebral perfusion (median, 28 minutes). Patch material was not used for aortic augmentation, and no patient underwent a posterior tracheopexy or rotational esophagoplasty. Postoperative length of stay ranged from 4 to 31 days (median, 5 days). One patient required a temporary tracheostomy for bilateral recurrent laryngeal nerve paresis, which recovered. One patient required an aortic extension graft to alleviate esophageal compression from an unusual ectatic esophageal course. All patients had relief of airway symptoms and dysphagia.
CONCLUSIONS
In properly selected patients with a right aortic arch and circumflex aorta, aortic uncrossing is a safe and effective therapy to treat airway and esophageal compression. The procedure can be conducted with deep hypothermic circulatory arrest or antegrade cerebral perfusion. Careful attention to the location of the esophagus and recurrent laryngeal nerves is required.
Topics: Humans; Infant; Child, Preschool; Child; Aorta; Aorta, Thoracic; Bronchoscopy; Vascular Surgical Procedures; Perfusion
PubMed: 37406764
DOI: 10.1016/j.jtcvs.2023.06.013 -
The Annals of Thoracic Surgery Jun 2022
Topics: Aortic Dissection; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Humans; Treatment Outcome; Vascular Surgical Procedures
PubMed: 34929142
DOI: 10.1016/j.athoracsur.2021.11.035 -
Journal of Endovascular Therapy : An... Oct 2022Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular... (Review)
Review
BACKGROUND
Ascending aorta and aortic arch diseases have an increasing interest among cardiovascular specialists regarding diagnosis and management. Innovations in endovascular surgery and evolution of open surgery have extended the indications for treatment in patients previously considered unfit for surgery. The aim of this systematic review of the literature was to present and analyze current cardiovascular guidelines for overlap and differences in their recommendations regarding ascending aorta and aortic arch diseases and the assessment of evidence.
METHODS
The English medical literature was searched using the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 2009 to December 2020. Recommendations on selected topics were analyzed, including issues from definitions and diagnosis (imaging and biomarkers) and indications for treatment to management, including surgical techniques, of the most important ascending aorta and aortic arch diseases.
RESULTS
The initial search identified 2414 articles. After exclusion of duplicate or inappropriate articles, the final analysis included 5 articles from multidisciplinary, cardiovascular societies published between 2010 and 2019. The definition of non-A-non-B aortic dissection is lacking from most of the guidelines. There is a disagreement regarding the class of recommendation and level of evidence for the diameter of ascending aorta as an indication. The indication for treatment of aortic disease may be individualized in specific cases while the growth rate may also affect the decision making. The role of endovascular techniques has not been established in current guidelines except by 1 society. Supportive evidence level in the management of aortic arch diseases remains limited.
CONCLUSION
In current recommendations of cardiovascular societies, the ascending aorta and aortic arch remain a domain of open surgery despite the introduction of endovascular techniques. Recommendations of the included societies are mostly based on expert opinion, and the role of endovascular techniques has been highlighted only from 1 society. The chronological heterogeneity apparent among guidelines and the inconsistency in evidence level should be also acknowledged. More data are needed to develop more solid recommendations for the ascending aorta and aortic arch diseases.
Topics: Aorta; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Aortic Diseases; Blood Vessel Prosthesis Implantation; Endovascular Procedures; Humans; Treatment Outcome
PubMed: 34873944
DOI: 10.1177/15266028211061271 -
Seminars in Thoracic and Cardiovascular... 2021Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement...
Aortic arch pathologies have been a surgical challenge, involving cerebral, visceral and myocardial protection. Innovative techniques including total arch replacement and frozen elephant trunk had evolved over last decades with promising mid-term outcomes. We evaluate our mid-term outcomes on total arch replacement with frozen elephant trunk and the role of timely second staged interventions. Between August 2014 and April 2020, 41 patients with aortic arch pathologies underwent total arch replacement with frozen elephant trunk with Thoraflex-Hybrid-Plexus device (Vascutek, Inchinnan, Scotland). Patients' perioperative, clinical and radiological outcomes were reviewed. Post discharge survival (n = 37) at 3 year was 100%. Overall survival of 85.3% over a median follow up of 3.3 years, inpatient mortality of 9.8%. Distribution of aortic pathologies with acute type A dissection or intramural hematoma (n = 15, 36.6%), thoracic aortic aneurysm, including arch and descending aortic aneurysm (n = 9, 22%) and chronic aortic dissection including chronic type A and type B dissections (n = 13, 31.7%). Mean operative, circulatory arrest, and antegrade cerebral perfusion time were 417 ± 121 minutes, 89 ± 28 minutes, and 154 ± 43 minutes, respectively. Second stage procedures were performed in 32% and distal stent graft induced new entry was observed in 19% of patients. We reported an Asian series of Thoraflex with outstanding midterm clinical outcomes, given descending aortic pathologies were tackled with a timely second stage interventions. The observation of aortic remodeling and distal stent graft induced new entry requires further investigations.
Topics: Aftercare; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Humans; Patient Discharge; Retrospective Studies; Stents; Treatment Outcome
PubMed: 33181309
DOI: 10.1053/j.semtcvs.2020.11.016 -
Asian Cardiovascular & Thoracic Annals Jan 2023Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high...
Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high hospital mortality rate. Open aortic surgery for ATAAD is always required to save the patient, particularly elderly patients. Tear-oriented surgery is recommended as the frontline treatment for ATAAD, and hemiarch replacement (HAR) is sufficient because the primary entry is often observed in the ascending aorta (60%-70%). However, HAR has some drawbacks, such as new creation of an anastomotic entry and unfavorable distal aortic remodeling during long-term follow-up. Although total arch replacement (TAR) is a demanding procedure, it is another useful option for ATAAD. Proper patient selection for TAR is controversial. Standardized procedure for TAR, including the optimal brain protection methods and the use of excellent sealed vascular prosthetic grafts, has been established over the past decades. Therefore, TAR is increasingly being selected for HAR in patients who are young or have enlarged aortic arch, severely dissected supra-aortic arch vessels, or hereditary thoracic aortic disorders. The emerging technology of commercially available frozen elephant trunk accelerated the application of TAR, facilitates distal anastomosis, and improves distal aortic remodeling. Although further evidence is required, TAR could be the best choice for HAR for selected patients. Currently, appropriate selection of the surgical technique is important to maximize the benefits of open surgery for ATAAD.
Topics: Humans; Aged; Blood Vessel Prosthesis Implantation; Treatment Outcome; Retrospective Studies; Postoperative Complications; Acute Disease; Aorta, Thoracic; Aortic Aneurysm, Thoracic
PubMed: 35509182
DOI: 10.1177/02184923211073374