Congenital vascular rings: a clinical challenge for the pediatrician

Variations in the Evaluation and Management of Vascular Rings: A Survey of American Clinicians

Vascular rings are arterial malformations that lead to the compression of the trachea and/or esophagus. While "tight" rings often produce symptoms and require surgery, "loose" rings rarely produce symptoms. Given advances in fetal echocardiography, this diagnosis is now more often made prenatally. This poses a new conundrum in the management of asymptomatic patients, leading to practice variation and creating a target for clinical system improvement. Hence, we conducted this survey aiming to demonstrate the practice variation existing in current evaluation and management of these patients. An anonymous web-based survey was distributed to several listservs for pediatric cardiologists and pediatric cardiothoracic surgeons. Survey questions targeted respondent practice characteristics, testing obtained, and indications for testing or surgical referral. In total 61 responses were received, predominantly from pediatric cardiologists (95%) in the United States (97%). About 60% of clinicians reported frequently diagnosing patients with vascular rings by fetal echocardiogram, with only about 20% diagnosing them frequently on evaluation of symptoms. Computed tomography angiography and echocardiogram were the most common imaging modalities employed. Most clinicians obtained cross-sectional imaging at the time of diagnosis and referred to surgery once patients had at least occasional symptoms. Respondents demonstrated a low degree of agreement (Krippendorf's alpha 0.48). Few statistically significant patterns were identified between respondents based on their practice characteristics. This study identified significant variation between clinicians regarding the evaluation and management of vascular rings. Further research or expert opinions may help to standardize practice, saving costs and improving the quality of care for affected patients.

Bronchoscopy findings in children with congenital lung and lower airway abnormalities

Congenital lung and lower airway abnormalities are rare, but they are an important differential diagnosis in children with respiratory diseases, especially if the disease is recurrent or does not resolve. The factors determining the time of presentation of congenital airway pathologies include the severity of narrowing, association with other lesions and the presence or absence of congenital heart disease (CHD). Bronchoscopy is required in these cases to assess the airway early after birth or when intubation and ventilation are difficult or not possible. Many of these conditions have associated abnormalities that must be diagnosed early, as this determines surgical interventions. It may be necessary to combine imaging and bronchoscopy findings in these children to determine the correct diagnosis as well as in operative management. Endoscopic interventional procedures may be needed in many of these conditions, ranging from intubation to balloon dilatations and aortopexy. This review will describe the bronchoscopic findings in children with congenital lung and lower airway abnormalities, illustrate how bronchoscopy can be used for diagnosis and highlight the role of interventional bronchoscopy in the management of these conditions.

Narrowing Down the Symptomatology of Isolated Vascular Rings in Children

Vascular rings may cause respiratory or gastrointestinal symptoms due to compression of the trachea and/or esophagus. Advances in imaging have enabled early detection in asymptomatic patients posing new management dilemmas. Surgery is expected to relieve symptoms, although this has not been well studied. We sought to evaluate the presence and pattern of symptoms associated with vascular rings before surgical intervention and to detail symptom resolution after surgery. A 10-year retrospective review of patients diagnosed with an isolated vascular ring was performed between January 2010 and December 2019. 100 patients were identified; 35 double aortic arch (DAA) and 65 right aortic arch and left ligamentum arteriosum (RALL). 73 patients were symptomatic on presentation; 47 had respiratory, 5 had gastrointestinal, and 21 had both types of symptoms. Surgical repair was performed in 75 patients; 74 were symptomatic. Respiratory symptoms were more likely in patients with preoperative tracheal narrowing (p < 0.001). Moderate-severe respiratory symptoms led to surgery in RALL patients (OR 10.6, p = 0.0001). DAA patients were more likely to undergo surgery (p < 0.001) irrespective of symptom severity. At a median post-surgical follow-up of 4 months, there was a significant reduction in symptom burden (p < 0.001), except for asthma symptoms (p = 0.131). Symptom resolution was not dependent on the vascular ring anatomy (p = 0.331) or the age at operation (p = 0.158). Vascular rings are typically accompanied by respiratory symptoms and less commonly GI symptoms, both of which resolve in most patients after surgery. Those who present predominantly with asthma-like symptoms may not achieve resolution after surgery.

Association Between Airway Stenosis Degree and Respiratory Distress in Infants With a Vascular Ring

Background Although the number of cases of prenatally diagnosed vascular rings is increasing, some cases may remain asymptomatic, and no indicator of the appearance of dyspnea has been established. Thus, we aimed to determine the relationship between the degree of airway compression by the vascular ring on contrast-enhanced computed tomography (CT) and respiratory distress. Methods This is a retrospective study of nine patients diagnosed with vascular rings at a single hospital from July 2010 to December 2019. Data regarding the patient's clinical characteristics, such as prenatal diagnosis, vascular ring type, complicated cardiac disease, and presence or absence of surgery, were recorded. Airway assessment on contrast-enhanced CT was measured in the axial cross-section. Statistical analysis was performed using Statistical Product and Service Solutions (SPSS) (version 25.0; IBM SPSS Statistics for Windows, Armonk, NY). Results Five of the eight patients had respiratory distress. Patients with respiratory distress were less likely to have been diagnosed prenatally (p = 0.04) and had smaller stenosis degree of anteroposterior diameter (p = 0.03). Conclusion Contrast-enhanced CT is useful in patients with vascular rings. Our study suggests that the stenosis degree of the anterior-posterior diameter of the airway is related to dyspnea.

A neonatal case of vascular ring with Alagille syndrome

A female infant, born at 37 week 5 days to a mother via induced vaginal delivery for preeclampsia, was prenatally diagnosed with a right aortic arch with vascular ring. On the third day of life, the infant exhibited a bronze-gray coloration, and a direct bilirubin of 1.7 mg/dL was detected. The abdominal ultrasound did not visualize the gallbladder. Clinically, the infant displayed features consistent with Alagille syndrome, including unusual facial appearance, butterfly vertebrae, cardiovascular defects, and cholestasis. The geneticist noted that the mother of the patient also exhibited similar features. Both the infant and the mother were diagnosed with Alagille syndrome, both having the same heterozygous JAG1 gene (NM_000214.2) variant (c.1890_1893del, p.Ile630Metfs*112). We believe that the vascular ring observed in our patient is the first reported instance of a vascular ring associated with Alagille syndrome.

Post-operative Outcomes for Vascular Rings: A Systematic Review and Meta-analysis

OBJECTIVES

Vascular rings may cause tracheal and/or oesophageal compression. For many patients, symptoms/signs have been present for a long period before diagnosis. However, in the era of prenatal diagnosis, some units advocate universal early surgery. The risks and efficacy of surgery must be known to adequately counsel for the operation. This meta-analysis sought to define the morbidity and mortality associated with surgical correction, and persistent post-operative symptoms.

METHODS

PubMed, Cochrane Library and CINAHL databases were searched for studies that described the outcome of patients undergoing surgery for a double or right aortic arch (DAA or RAA). Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled rates of mortality, surgical complications, reintervention, and persistent follow-up symptoms.

RESULTS

Nineteen eligible studies were included comprising 18 studies describing outcomes for DAA surgery and 15 for RAA surgery. For DAA surgery, overall mortality rate was 0% [95% confidence interval (CI) 0.0-1.0], post-surgical complication rate 18% [95% CI: 12.0-23.0], prevalence of reintervention 3% [95% CI: 1.0-5.0] and prevalence of symptoms at last follow-up was 33% [95% CI: 17.0-52.0]. For RAA surgery, overall pooled mortality was 0% [95% CI: 0.0-0.0], prevalence of post-surgical complications was 15% [95% CI: 8.0-23.0], reintervention rate was 2% [95% CI: 0.0-4.0], prevalence of symptoms at last follow-up was 40% [95% CI: 26.0-55.0].

CONCLUSIONS

While surgery to correct a vascular ring is safe, the rate of persistent symptoms is high and further strategies must be sought to reduce this burden.

Pediatric airway compression in aortic arch malformations: a multidisciplinary approach

Background

Aortic arch malformations (AAMs) should be suspected in the presence of persistent respiratory symptoms despite medical treatment or feeding problems at the pediatric age.

Aim

We report a descriptive cohort of patients with AAMs and the local management protocol applied.

Methods

A total of 59 patients with AAM were retrospectively reviewed. Three groups were identified: double aortic arch (DAA), group 1; complete vascular ring (non-DAA), group 2; and anomalous origin of the innominate artery (IA), group 3.

Results

Prenatal diagnosis was available for 62.7% of the patients. In all, 49.2% of children were symptomatic. There was a significantly different prevalence of respiratory symptoms within the three groups: 73.7% in group 1, 24.2% in group 2, and 100% in group 3 (p-value: <0.001). Surgery was considered in the presence of symptoms in patients with DAA and in those with reduction of the tracheal section area greater than 50%. A total of 52.5% of the patients underwent surgical repair (median age 6 months). The median follow-up interval was 21.9 months. Respiratory symptoms improved in most symptomatic patients.

Conclusions

No specific protocols are available for the management of patients with AAMs. Conservative treatment seems to be reasonable for asymptomatic patients or those with airway stenosis less than 50%. A close follow-up is necessary to identify early patients who become symptomatic.

Long term respiratory morbidity in patients with vascular rings: a review

Abnormalities in position and/or branching of the aortic arch can lead to vascular rings that may cause narrowing of the tracheal lumen due to external compression, or constriction of the oesophagus, causing symptoms that vary in relation to the anatomical vascular pattern and the relationship between these structures. Respiratory morbidity related to external airways compression is a major concern in children affected by vascular rings. Clinical presentation depends on the severity of the tracheal lumen reduction and the presence of associated tracheomalacia. Recurrent respiratory infections, wheezing, atelectasis, and hyperinflation are mostly reported. As they are nonspecific and therefore difficult to recognize, attention should be given to all children with history of respiratory distress, extubation failure, noisy breathing, and recurrent respiratory infections. Early diagnosis and referral to specialized centres can prevent the long-term complications and improve the respiratory outcomes of these patients.

Progressive Dysphagia and Chronic Abdominal Pain From Vascular Anomalies: A Case Report and Literature Review

Median arcuate ligament syndrome and symptomatic aberrant right subclavian artery are uncommon in the pediatric population and are rarely found in the same individual. We present the case of a teenager with 2 rare vascular anomalies leading to chronic postprandial abdominal pain, dysphagia, and weight loss. The purpose of this case report is to raise awareness about these rare anomalies and their presentations in the pediatric population.

Evaluation of the trachea in fetuses with double aortic arch using prenatal ultrasound: a retrospective cohort study

BACKGROUND

Double aortic arch is the most common form of complete vascular ring. The trachea and/or esophagus could be compressed by the complete vascular ring, which may lead to early respiratory and/or esophageal symptoms in children with double aortic arch. Accurate prenatal assessment of tracheal compression could provide relevant information for perinatal clinical management of double aortic arch and emergency treatment of infants with double aortic arch. The fetal trachea is filled with amniotic fluid and can be clearly visualized with prenatal ultrasound. Previous studies reported the use of prenatal ultrasound to measure the tracheal internal diameters in normal fetuses and showed a linear correlation between the fetal tracheal internal diameters and gestational age. However, to the best of our knowledge, few studies have quantitatively evaluated tracheal compression in fetuses with double aortic arch using ultrasound.

OBJECTIVE

This study aimed to evaluate the tracheal compression caused by the vascular ring in fetuses with double aortic arch using prenatal ultrasound and to analyze the relationship between tracheal compression and postnatal clinical symptoms.

STUDY DESIGN

The data of fetuses with double aortic arch diagnosed with prenatal ultrasound at 2 institutions from January 2011 to April 2021 were retrospectively analyzed. Singleton pregnancies with normal fetuses as the control group were prospectively recruited. The tracheal compression-evaluated by comparing the tracheal internal diameter z scores against the gestational age-was assessed in fetuses with double aortic arch and in normal fetuses. The live-born infants with double aortic arch were divided into symptomatic and asymptomatic groups for the comparison of z scores. The receiver operating characteristic curve for the tracheal internal diameter z score cutoffs and prediction of symptomatic infants with double aortic arch was plotted. Intraobserver and interobserver agreements were investigated.

RESULTS

A total of 26 fetuses with double aortic arch were diagnosed, and 14 fetuses (53.8%) with double aortic arch were delivered alive. Among the 14 live-born infants, 7 (50.0%) were symptomatic, whereas 7 (50.0%) were asymptomatic. The tracheal internal diameter z scores were significantly lower in the double aortic arch group than in the normal groups (-0.62±1.36 vs 0.00±0.78; P<.001). The tracheal internal diameter z scores were significantly lower in the symptomatic group than in the asymptomatic group (-1.42±0.92 vs -0.49±0.96; P=.018). The area under the curve was 0.878 (95% confidence interval, 0.689-1.000). Using a tracheal internal diameter z scores cutoff of -1.21, the sensitivity was 71%, and the specificity was close to 100%. The intraclass correlation coefficients of interobserver and intraobserver agreements were 0.987 (95% confidence interval, 0.980-0.992) and 0.975 (95% confidence interval, 0.955-0.987), respectively.

CONCLUSION

The clinical symptoms in infants with double aortic arch were associated with prenatal tracheal compression, which can be prenatally evaluated using ultrasound. If fetuses are diagnosed with double aortic arch, prenatal surveillance of the tracheal internal diameters and comparison with z score reference ranges could provide pertinent information that would aid perinatal clinical management.

Congenital Aortic Vascular Ring: In-Utero Sonographic Assessment of Tracheal Patency and Postnatal Outcome

OBJECTIVE

 Congenital aortic vascular ring may present after birth with variable degrees of respiratory distress due to tracheal compression. The aim of this study was to prospectively evaluate in utero tracheal patency in correlation with postnatal outcome.

METHODS

 During an eight-year period, fetuses with aortic arch abnormality encircling the trachea and forming a complete ring were recruited for the study. Tracheal patency was classified as: no compression, partial compression, or complete compression. Postnatal MRI/CTangio studies were performed and outcome data was retrospectively analyzed from the medical records.

RESULTS

 Among the 46 fetuses recruited to the study, 38 had right aortic arch (RAA), and 8 presented with double aortic arch (DAA). In the RAA group 35 (92.1 %) of the fetuses presented no compression and 34 (97.1 %) of them were asymptomatic in the long-term follow-up. Three fetuses (7.9 %) in this group presented in utero compression: one was terminated at 16 weeks of gestation due to associated ominous findings, and the other two had mild respiratory symptoms around 12 months of age and underwent surgery with a good outcome. In the DAA group, all fetuses presented in utero with tracheal compression. Seven showed partial and one complete compression. Among the seven with partial compression, six were symptomatic and underwent surgery. The case with severe airway occlusion had emergency tube insertion in the delivery room and underwent surgery at 7 days but died from severe respiratory complications.

CONCLUSION

 This is the first study to evaluate in utero tracheal patency in cases with vascular ring. It allows better prenatal and postnatal workup and follow-up including potentially life-threatening respiratory failure.

Don't go barking up the wrong tree: Thinking beyond infection in a toddler with stridor

A toddler presented to the emergency department with persistent stridor and barky cough for 4 weeks and progressive dysphagia for 1 week. During this time, he had sought medical attention 6 additional times and had been treated for pneumonia, wheezing and croup, receiving antibiotics and several courses of steroids without improvement. On the final presentation, airway imaging did not reveal a foreign body. However, bedside laryngoscopy demonstrated bilateral vocal cord paralysis. Further imaging revealed an intracranial posterior fossa mass which provided the unifying diagnosis for his persistent symptoms.

Tracheal bronchus: a rare cause of recurrent pneumonia in adults

Tracheal bronchus, also known as bronchus suis, is a rare congenital anomaly of the airway where an accessory bronchus originates directly from the trachea. With an estimated incidence of 0.001%-2.0%, this condition is rarely reported in literature. It is usually discovered as an incidental finding in an otherwise asymptomatic individual. However, it can act as a focus of recurrent infection or present as persistent radiographic infiltrates. Multidetector CT imaging and bronchoscopy play a crucial role in the identification of this entity. We hereby report the case of a middle-aged man who presented with recurrent right upper lobe pneumonia, which was found to be due to an underlying tracheal bronchus.

Vascular rings

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.

Mid-term results of vascular ring surgery

BACKGROUND

Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery.

METHODS

Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time.

RESULTS

Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bronchodilator use,18.3% had at least one episode of pneumonia per year, 31% of children had dyspnoea or respiratory limitation, and 12.7% while doing physical activities. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up.

CONCLUSIONS

Surgical division of vascular rings results in significant clinical improvement within 1 year; nevertheless, some patients remain symptomatic to some degree. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Further evaluation is warranted to assess the nature of residual symptoms and explore whether anatomical causes can be identified leading to surgical modifications.

A Delayed Anatomic Diagnosis and Management Challenge in an Initially Asymptomatic Infant With Type II Pulmonary Artery Sling: A Case Report

Pulmonary artery sling (PAS) is a rare but fatal malformation. Patients with PAS tend to develop obstructive symptoms in few weeks of life. Conversely, some patients may be otherwise mild or asymptomatic in their early life. Currently, no consensus on the intervention timing and treatment strategy for asymptomatic and mild cases has been reached. Moreover, the extent of tracheal stenosis is another determining factor for the choice of intervention timing since clinical symptoms might not correspond well with the degree of stenosis. Lack of comprehensive assessment of entire airways confer underestimation of disease severity and in turn improper choice of treatment regimens and poor outcomes. Herein, we described an infantile case of PAS, who was scheduled initially for periodic outpatient follow-up on account of the absence of symptoms and inadequate imaging assessment at diagnosis. The patient developed recurrent wheezing and progressive respiratory distress at 7 months of age. After left pulmonary artery (LPA) reimplantation without tracheal intervention, bronchoscopy was performed due to failure to wean from mechanical ventilation, which demonstrated complete tracheal cartilage rings, a long segment tracheal stenosis, a low tracheal bifurcation at T6, and the absence of a separate right middle lobe bronchus. The patient was finally diagnosed with type IIb PAS and extubated successfully following conservative treatment. Miserably, neurological sequelae were devastating, leading to poor outcomes. Comprehensive airway evaluation using bronchoscopy is substantial to early identification of all components responsible for airway compromise in PAS anatomic subtypes. Considering severe concomitant maldevelopment of the bronchial tree in children with type IIb PAS, early and complete correction by surgery might decrease perioperative morbidities and mortalities of these patients.

Chromosomal Microarray Analysis for the Fetuses with Aortic Arch Abnormalities and Normal Karyotype

Background

Aortic arch abnormalities (AAA) are abnormal embryologic developments of the aorta and its branches. Their outcomes often depend on their association with other congenital diseases and genetic testing results.

Objective

This study aimed to evaluate the yield of chromosomal microarray analysis (CMA) in fetuses with different patterns of AAA and normal karyotype.

Methods

Data from 158 pregnancies referred for prenatal CMA testing due to fetal AAA were obtained between April 2016 and April 2019. Fetuses with isolated AAA, AAA accompanied by soft ultrasound markers, and AAA with other ultrasound malformations were classified into groups A, B, and C, respectively. Cases with detectable karyotype aberrations were excluded from the study.

Results

Twenty cases (12.7%) of submicroscopic anomalies were detected in 158 cases with normal karyotype, comprising 16 cases (10.1%) of clinically significant variants, two cases (1.3%) of variants of unknown significance, and two variants (1.3%) that were likely benign. Microdeletion of 22q11.2 accounted for 25% (4/16) of the clinically significant variants. The overall incremental yields by CMA in group A, group B, and group C were 1.8%, 2.3%, and 24.1%, respectively. Except for double aortic arch, the incremental yield of clinical significant findings for each type of AAA in group C was much higher than that in group A and group B. In group A, a clinically significant variant was only detected in one fetus with right aortic arch (RAA) (1.8%, 1/57).

Conclusions

In addition to 22q11.2 microdeletion, many other clinically significant submicroscopic variants are present in fetuses with AAA, especially in fetuses with other ultrasound malformations. Although CMA is always recommended in the presence of any malformation in many countries, our results suggest insufficient evidence to recommend CMA in fetuses with isolated AAA, except for isolated RAA.

Recurrent croup in a young child: look beyond airways disease

We reported here a boy aged 5 years who presented for the evaluation of recurrent croup since infancy. On chest examination, breath sounds were reduced throughout the right lung field with a shifting of the trachea and cardiac apex to the right side. The chest radiograph showed a small right lung with decreased vascularity, hyperinflated left lung and mediastinum shifted towards the right side. Flexible bronchoscopy revealed tracheomalacia with left bronchomalacia due to external pulsatile compression. In CT angiogram, the right pulmonary artery (PA) was absent with dilated left PA. Echocardiography did not show any features of pulmonary arterial hypertension (PAH). Since the child was growing well, and there was no limitation of activity and evidence of PAH, he was managed conservatively and kept on follow-up. Though unilateral absent PA is a rare condition, it should be suspected in children with unilateral hypoplastic lung.

Noisy Breathing in an Infant: A Case Report

The diagnosis of vascular rings is challenging and may be delayed as symptoms overlap with more common conditions associated with childhood. Underlying genetic associations of this condition remain largely undiscovered. In this report, we present a patient with a double aortic arch and highlight the importance of diagnostic imaging. We also engage in a review of the important genetic considerations.

The Role of Lung Function Testing in Newborn Infants With Congenital Thoracic Arterial Anomalies

Introduction: Congenital thoracic arterial anomalies (CTAAs), such as complete or incomplete vascular rings, pulmonary artery sling, and innominate artery compression syndrome, may cause severe tracheomalacia and upper airway obstruction. An obstructive ventilatory pattern at lung function testing (LFT) has been suggested in the presence of CTAA. The severity of obstruction may be evaluated by LFT. Little is known about the use of LFT in newborn infants with CTAA. The aim of our study is to evaluate the role of LFT in CTAA diagnosis. Methods: This is a retrospective study, conducted between February 2016 and July 2020. All CTAA cases for whom LFT was performed preoperatively were considered for inclusion. Tidal volume (Vt), respiratory rate, and the ratio of time to reach the peak tidal expiratory flow over total expiratory time (tPTEF/tE) were assessed and compared to existing normative data. Demographics and CTAA characteristics were also collected. Results: Thirty cases were included. All infants with CTAA showed a significantly reduced Vt and tPTEF/tE, compared to existing normative data suggesting an obstructive pattern. No significant differences were found for LFT between cases with a tracheal obstruction <50% compared to those with tracheal obstruction ≥50%, or between cases with and without symptoms. Sixteen infants (53.3%) had respiratory symptoms related to CTAA. Of these, only two cases had also dysphagia. Conclusion: LFT values were significantly reduced in cases with CTAA before surgery. LFT represents a potential feasible and non-invasive useful tool to guide diagnosis in the suspect of CTAA.

Measuring inflammation in paediatric severe asthma: biomarkers in clinical practice

Severe asthma in children is a highly heterogeneous disorder, encompassing different clinical characteristics (phenotypes) and immunopathological pathways (endotypes). Research is focusing on the identification of noninvasive biomarkers able to predict treatment response and assist in designing personalised therapies for severe asthma. Blood and sputum eosinophils, serum IgE and exhaled nitric oxide fraction mostly reflect type 2 airway inflammation in children. However, in the absence of available point-of-care biomarkers, the diagnosis of non-type 2 asthma is still reached by exclusion. In this review, we present the most recent evidence on biomarkers for severe asthma and discuss their implementation in clinical practice. We address the methods for guiding treatment decisions and patient identification, focusing on the paediatric age group.

Noninvasive biomarkers should be integrated with clinical findings to assist in diagnosing and guiding personalised therapies for severe asthma in childrenhttp://bit.ly/2JPvKFV

Severe uncontrolled asthma in children: practical approach on diagnosis and management

Severe uncontrolled asthma in children is a complex and heterogeneous disease and is considered a challenge for the pediatricians. Although nearly 5% of children with asthma present with a severe uncontrolled disease, these patients and their caregivers face a significant burden, including troublesome persistent symptoms, life-threatening acute attacks, medication side effects, impaired school performance, neuropsychological problems, and lower quality of life (QoL). Moreover, these patients also account for substantially higher healthcare resource use and costs than average patients with asthma. Thus, it is essential to accurately define and diagnose severe asthma in children as they potentially need close monitoring and additional treatment with advanced therapies. This review aims to update knowledge on diagnosis and management of severe uncontrolled asthma in childhood. We describe a practical approach to differentiate children with difficult-to-treat asthma from those with true severe therapy-resistant asthma. Moreover, the recent advances in the understanding of the pathogenetic mechanisms and inflammatory mediators involved in asthma have paved the way for the development of a precision medicine approach. In this context, we analyze approved personalized therapies for severe uncontrolled asthma, focusing on the pediatric indications.

The long-term outcome of an isolated vascular ring - A single-center experience

BACKGROUND AND OBJECTIVES

The aim of this study is to document the long-term outcome of patients with a vascular ring.

METHODS

A single-center retrospective review of clinical symptoms was conducted in all patients born between 1980 and 2013, diagnosed with a complete vascular ring and at least 2 years of follow-up. Data were extracted from patient files and clinical symptoms were assessed by questionnaires sent to the parents. Age and diagnostic tools, type of surgery, postoperative complications, and the prevalence of clinical symptoms (stridor at rest, stridor with exercise, cough, exercise intolerance, dysphagia, and frequent respiratory infections) were reviewed.

RESULTS

Fifty-one patients were included. The diagnosis was made before the age of 2 in 35/51. Surgery was performed in 41/51 patients with a limited number of reversible complications. The median follow-up was 8 (IQR 5-12) years. After 2 years, 21/51 patients were asymptomatic: 2/7 asymptomatic patients at diagnosis became symptomatic and symptoms resolved in 16/44 initially symptomatic patients. Consequently, 30/51 patients still had symptoms after 2 years. Of these, 16 had partial improvement, 5 stable symptoms, and 9 aggravation of symptoms. After 10 years, 26/36 patients were free of complaints. The most frequent long-term symptom was stridor.

CONCLUSION

Surgical treatment of a congenital vascular ring is safe and mostly performed in patients with a double aortic arch. Conservative treatment for patients with little symptoms seems to be justifiable. A considerable number of patients have residual long-term symptoms after surgical relief of the vascular ring.

Surgical management of critical congenital malformations in the delivery room

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.

Congenital vascular ring

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.

Targeted Therapy for Severe Asthma in Children and Adolescents: Current and Future Perspectives

Severe asthma in children remains a significant issue. It places a heavy burden on affected individuals and society as a whole in terms of high morbidity, mortality, consumption of healthcare resources, and side effects from high-dose corticosteroid therapy. New, targeted biologic therapies for asthma have emerged as effective add-on options, complementing our expanding understanding of asthma phenotypes/endotypes and the underlying immunopathology of the disease spectrum. They include omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Omalizumab represents the first available therapeutic option for allergic asthma in patients as young as 6 years of age. Its efficacy and safety have been established by several randomized controlled trials specifically conducted in pediatric patients, leading to its final registration > 10 years ago. Three new interleukin (IL)-5 targeted agents, mepolizumab, reslizumab, and benralizumab, have been approved for the treatment of severe eosinophilic asthma starting from 6 years of age, and varying by country. More recently, dupilumab, a targeted agent against the IL-4 receptor α-chain, was approved for patients ≥12 years of age in the United States after pivotal trials were completed. The late-stage clinical testing of these targeted agents has mostly involved patients aged 12 years and up, and the application of those data to younger children can be inappropriate and carry risk. The efficacy and safety of these newer biologics in children should be supported by adequate research within this targeted age group. In this review, we will present the most recent evidence on these five biological therapies for severe asthma and will discuss dosage and administration, their efficacy, safety, and future prospects, with a focus on the pediatric age group, defined as age < 18 years.

Surgical reconstruction for congenital tracheal malformation and pulmonary artery sling

Background

Congenital tracheal malformations are less common than congenital cardiac diseases and surgical repair of these anomalies is complex. We sought to examine the surgical treatment and outcomes in cases of tracheal anomalies presenting with or without associated congenital malformations.

Methods

We retrospectively reviewed the demographic, clinical, and imaging data of 49 children who underwent surgery for congenital tracheal malformations between August 2013 and September 2017. Data were collected from the hospital records.

Results

In all, 49 patients (male, 30; female, 19) underwent surgeries at our center. The children were of ages between 3 and 36 months (average: 9.7 months). Associated congenital lesions included sling in31/49 (63%), vascularring: in 2/49; ventriculoseptaldefectin5/49; Fallot’s tetraology in 2/49 (4.1%), and imperforate anus in 3/49 (6.1%). The outcomes of surgery were excellent in 42(85.7%) cases, good in 3 cases, while mortality occurred in 4(8.1%) cases. All cases of tracheal stenosis without any change in tracheobronchial arborization, 10/12 cases of bridge carina, and all cases of tripod carina were reconstructed using the slide tracheoplasty technique. Antetracheal translocation was performed for correction of associated pulmonary sling, without reimplantation of the pulmonary artery.

Conclusions

Reconstructive surgery is a feasible treatment option for congenital tracheal malformations. Slide tracheoplasty can be safely applied in all cases for the correction of tracheal stenosis. Segment resection was not required for any portion of the trachea. Pulmonary artery translocation is safe and effective for patients with pulmonary artery sling, rather than reimplantation. Mortality was associated with severe cardiac complications.

The Natural and Unnatural History of Congenital Aortic Arch Abnormalities Evaluated in an Adult Survival Cohort

BACKGROUND

This study describes the different types of congenital vascular rings according to their anatomy, symptoms, and age at clinical onset and reports the surgical outcomes.

METHODS

A retrospective observational database study was conducted, reviewing the medical charts of 69 adult survivors with a history of a vascular ring, identified from the Dutch Congenital Cor vitia database.

RESULTS

Median age at presentation was 8.5 years (0-53.0 years). Thirty patients (43.5%) had a "left aortic arch with aberrant right subclavian artery," 21 patients (30.4%) a "double aortic arch," and 16 patients (23.2%) a "right aortic arch with aberrant left subclavian artery." The main symptomatology at presentation comprised respiratory symptoms (82.9%). Almost three-quarters of patients were also diagnosed with asthma/bronchial hyperreactivity. Patients with a double aortic arch had more symptoms than patients with a left aortic arch with aberrant right subclavian artery and right aortic arch with aberrant left subclavian artery (P < 0.001), requiring surgery most often (P < 0.001). In patients with childhood onset of symptoms, preoperative spirometry (ie, peak expiratory flows) was more often abnormal as compared with adult patients (P = 0.007). Surgery was performed in 42.0% of all patients at a median age of 17 years (0-63.0 years). Twenty-four (92.3%) of the operated patients showed improvement or complete relief of symptoms shortly after surgery. Of 26 asymptomatic nonoperated patients, 3 patients (11.5%) eventually developed symptoms.

CONCLUSIONS

The low incidence of vascular rings, their anatomic heterogeneity, and a wide range of common symptoms often lead to misdiagnosis. Clinical awareness is warranted as a large subset of patients could benefit from surgery, even at an adult age.

Quantified evaluation of tracheal compression in pediatric complex congenital vascular ring by computed tomography

Clinically, early diagnosis and treatment is important for survival of pediatric with vascular ring (VR) associated with congenital heart disease (CHD), and accurate evaluation of VR is a prerequisite for repair surgical. The study aimed to assess the quantitative characteristics of tracheal compression in pediatrics with VR and CHD using dual-source computed tomography (DSCT), and further provided effective information for surgical decisions. A total of 49 VR patients with CHD and 56 controls were enrolled. The tracheal quantitative measurements (short diameter, long diameter, tracheal area and tracheal length) were obtained, and the degree of tracheal compression was assessed. Our results indicated that VR associated with CHD may cause more serious and complex symptoms, and the greater tracheal compression were found on DSCT when more severe symptoms were present (r = 0.84). The degree of tracheal compression was significantly different within the VR group between those with and without surgery (P = 0.002). Finally, there were good agreement among (1-long diameter ratio), (1-short diameter ratio) and (1-area ratio) in patients and controls, respectively. This study indicated that DSCT enables provides accurate quantitative tracheal compression information for VR pediatrics associated with CHD, and evaluation of the degree of tracheal compression by 1-area ratio may contribute to the repair surgical of VR.

Correlation of Symptoms with Bronchoscopic Findings in Children with a Prenatal Diagnosis of a Right Aortic Arch and Left Arterial Duct

A right aortic arch (RAA) with a left arterial duct (LAD) together encircle the trachea and have the potential to cause tracheobronchial compression and published guidelines recommend bronchoscopy in symptomatic patients. The aim of the study was to describe the incidence of tracheal compression in a cohort of prenatally diagnosed RAA and LAD. Retrospective review of clinical course and imaging of prenatal cases of RAA and LAD assessed with flexible bronchoscopy over an 11-year period. 34 cases of prenatally diagnosed RAA with LAD underwent bronchoscopy at median age of 9 months (range 0.4-123) of whom 11 had respiratory symptoms and 23 were asymptomatic. In the neonatal period, three cases demonstrated respiratory symptoms. An aberrant left subclavian artery (ALSA) was identified in 29 cases. Pulsatile tracheal compression was identified in 32/34 (94%) cases and two cases showed normal tracheal appearances. Significant tracheal compression (> 70% occlusion) was present in 25/34 (74%) cases of which 16 were asymptomatic. Significant carinal compression (> 70% occlusion) was identified in 14/34 (42%) cases, an ALSA was observed in 13/14. Surgical relief of a vascular ring has been performed in 27 (79%) cases at a median age of 15 months (range 0.6-128 months). At surgery, a fibrous remnant of an atretic left aortic arch was identified in 11/27 (41%) cases. Significant tracheal compression may be present in infants even without symptoms. If early relief of airway compression is to be achieved to promote normal development of tracheal cartilage, early bronchoscopy should be considered.

Wheezing and dyspnoea caused by aberrant left innominate artery

We present a rare case of a branching anomaly of the aortic arch that resulted in wheezing and dyspnoea. The patient was a 60‐year‐old male with severe wheezing from babyhood, originally diagnosed with severe bronchial asthma. On auscultation, the inspiratory and expiratory wheezes appeared when the patient leaned forward. He also had difficulty in swallowing solid mass. Tests for airway reversibility and hyperresponsiveness were negative, and asthma treatment was ineffective. He had a right aortic arch. A barium oesophagogram and endoscopic examination indicated narrowing of the oesophagus from behind. Three‐dimensional reconstruction of enhanced chest CT images indicated a right aortic arch and an aberrant enlarged left innominate artery, which compressed and narrowed the oesophagus and trachea from behind. Although the patient had been diagnosed with intractable bronchial asthma, his symptoms were more likely caused by this mechanical narrowing as wheezing and dyspnoea disappeared completely after total aortic arch replacement operation.

Wheezing in Infancy: An Overview of Recent Literature

PURPOSE OF REVIEW

Wheezing in infancy is a common presentation with many potential causes. In writing this review, we sought to summarize the newest recommendations and testing available for the more common etiologies of wheezing.

RECENT FINDINGS

Regarding the diagnosis of asthma, the modified asthma predictive index has recently been established as a useful predictive tool. Non-breath held multidetector CT with 3D volume rendering airway images is also a newer helpful diagnostic tool for tracheomalacia due to ease of use and its 100% positive predictive value. We found vaccines have greatly reduced the prevalence of epiglottitis, while advances in surgery are improving outcomes in infants with vascular rings. Wheezing in infants is a common problem with an extensive differential diagnosis from relatively benign to life threatening. To prevent over-looking a diagnosis that potentially requires surgical correction or emergent care, we recommend a structured approach to the history and physical exam with targeted testing directed towards the most likely diagnoses as outlined in this review.

ALTE and Feeding Intolerance as a Presentation of Double Aortic Arch

Many children who are admitted to pediatric hospitals with the chief complaint of apparent life-threatening event (ALTE) are, in fact, well appearing by the time the inpatient medical team evaluates the patient. This presents a diagnostic and therapeutic challenge. We describe a case of a six-month-old full-term female presenting with an ALTE and found to have a double aortic arch, a congenital anomaly that usually presents with a more progressive onset of symptoms such as chronic cough, positional stridor, and feeding difficulties. This case highlights the importance of maintaining a broad differential in a patient presenting with findings of tracheoesophageal pathology on clinical exam.

Pediatric Chest Radiographs: Common and Less Common Errors

OBJECTIVE

Radiographic imaging of the pediatric chest presents several unique challenges and nuances, stemming from congenital variants and pathologic processes specific to this population. Errors in interpretation may lead to inappropriate further imaging, incurring additional radiation exposure and cost, as well as psychologic effects on the patients and their families.

CONCLUSION

Here, we aim to highlight some common and less common pitfalls in pediatric chest radiography, as well as some tools for avoiding potential mistakes.

A Rare Case of Esophageal Dysphagia in Children: Aberrant Right Subclavian Artery

Dysphagia is an impairment of swallowing that may involve any structures from the mouth to the stomach. Esophageal dysphagia presents with the sensation of food sticking, pain with swallowing, substernal pressure, or chronic heartburn. There are many causes of esophageal dysphagia, such as motility disorders and mechanical and inflammatory diseases. Infrequently dysphagia arises from extrinsic compression of the esophagus from any vascular anomaly of the aortic arch. The most common embryologic abnormality of the aortic arch is aberrant right subclavian artery, clinically known as arteria lusoria. This abnormality is usually silent. Here, we report a case of six-year-old child presenting to us with a history of progressive dysphagia without respiratory symptoms. A barium esophagogram showed an increase of the physiological esophageal narrowing at the level of aortic arch, while at esophagogastroduodenoscopy there was an extrinsic pulsatile compression of the posterior portion of the esophagus suggesting an extrinsic compression by an aberrant vessel. Angio-CT (computed tomography) scan confirmed the presence of an aberrant right subclavian artery.