Aortic arch anomalies: simplified classification: surgical experience with ten cases

Right-sided aortic arch and tetralogy of Fallot in humans--a morphological study of 10 cases

INTRODUCTION

A right-sided aortic arch (RAA) represents a rare anomaly of the cardiovascular system. In situs solitus, RAA is typically associated with malformations of the cardiac outflow tract such as tetralogy of Fallot (TOF). RAA is classified according to the course and ramification pattern and the position of the arterial duct. Varying data on the frequency of the RAA ramification patterns are reported in the literature.

METHODS

We examined 10 formalin-fixed human specimens aged 3 weeks to 10 years. In each case, we investigated the course of the aortic arch, its ramification and the position and course of the arterial duct/ligament as well as associated cardiac malformations.

RESULTS

Three different ramification patterns became evident: mirror-image branching (n=7), aberrant left subclavian artery (n=2) and isolated left subclavian artery (n=1). The arterial duct was situated either on the left side connecting the left pulmonary artery to the left subclavian artery (n=6) or on the right-hand side between the right pulmonary artery and the aortic arch (n=3). The duct was absent in one case. The most frequent combination was a mirror-image branching pattern with a left-sided arterial duct (n=4).

CONCLUSIONS

The various ramification patterns of the RAA are explained by differences in growth and involution of the embryonic double-aortic arch "anlage." Genetic factors as well as mechanical influences may be involved in the aetiology of RAA. The percentage of the various RAA patterns strongly depends on the examination material available.

Coarctation of the aorta with right aortic arch: surgical technique and new classification

BACKGROUND

The combination of right aortic arch and coarctation of the aorta has seldom been reported. This rare abnormality occurs as an isolated lesion or in association with other congenital defects, such as mixed gonadal dysgenesis and Turner's syndrome.

METHODS

The medical records of 2 patients who underwent operation for right aortic arch and aortic coarctation in our institution were reviewed together with case reports in the literature. Various surgical options have been reported: synthetic grafts, subclavian flap, and end-to-end anastomosis. End-to-end anastomosis is our method of choice for coarctation of the aorta and for right aortic arch with coarctation, even though an excessive amount of dissection is needed.

RESULTS

Both patients from our institution are doing well, with no sign of recoarctation in either patient. Our experience and recent advances in the understanding of the anatomy of this lesion led us to develop an alternative simplified classification for right aortic arch, which is presented here.

CONCLUSIONS

Right aortic arch and coarctation of the aorta is a rare morphologic combination. On the basis of our experience with repair of coarctation of the aorta and our review of the literature, we think that end-to-end anastomosis is the operative technique of choice with the best long-term results. Our simplified classification is easy to understand when dealing with right aortic arch.

Right aortic arch with aberrant left subclavian artery: symptomatic in adulthood

A 42 year old black woman presented initially with symptoms of acute aortic dissection. She subsequently had symptoms of esophageal obstruction that were proved aortographically to be due to right aortic arch with an aberrant left subclavian artery. Relief of the esophageal obstruction was achieved only after dividing the aortic arch posteriorly and freeing the trachea and esophagus from the surrounding structures.

Aortic arch anomalies in adult disorders of deglutition

Congenital vascular anomalies of the aortic arch are unusual etiologies of dysphagia in the adult. Swallowing abnormalities associated with compression of the esophagus primarily occur at birth or in the immediate neonatal period. However, as the result of arteriosclerotic vascular disease or aneurysm formation, anomalies which were asymptomatic postnatally may produce dysphagia in the adult. A retrospective analysis of 59 cases with aortic arch anomalies presenting initially in adulthood revealed characteristic clinical signs and symptoms. An aberrant right subclavian artery with left aortic arch was the most frequently encountered abnormality. The embryologic development of each vascular anomaly is described and the value of selective arteriography with contrast esophagography is stressed. Patients with minimal swallowing impairment are treated with dietary management alone. Surgical division of the anomalous artery is indicated only when severe dysphagia is associated with progressive life-threatening anorexia and weight loss.