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.

Thoracic Aortic Aneurysms and Arch Disease

Aortic arch and descending thoracic pathology have historically remained in the realm of open surgical repair. Technology is quickly pushing to bring these under the endovascular umbrella, with lower morbidity repairs proving safe in their early experience. Much work remains particularly for acute aortic syndromes, however, to understand who is best treated medically, surgically, endovascularly, or with hybrid approaches.

Management of prenatally detected vascular rings: a United Kingdom national survey

OBJECTIVE

To investigate UK variability in prenatal and postnatal management strategy of right aortic arch and double aortic arch (RAA/DAA).

METHODS

Online surveys were sent to senior physicians (consultants) of the National Fetal Cardiology Working Group regarding prenatal diagnosis, counselling, and perinatal management of antenatally diagnosed RAA/DAA and to the British Congenital Cardiovascular Association regarding postnatal management strategies.

RESULTS

There were 28 prenatal and 90 postnatal surveys completed. Prenatally, there was consensus for potential associated chromosomal/genetic anomalies, but there was variation in the risk quoted. Confidence in defining aortic arch morphology was reported by 43% (12/28) of fetal cardiologists. There was variation in what was felt to be possible symptoms/signs of a compressive vascular ring, postnatal investigation, postnatal management, follow-up duration of asymptomatic patients, and indications for surgical intervention.

CONCLUSION

This study has highlighted important areas for future research: improving accuracy of prenatal diagnosis, clarification of potential symptoms, optimal investigation strategies, and indications for surgery.

Recognising ligamentous atresia in double aortic arch

Ligamentous atresia of the left side of a double arch distal to the left subclavian artery is a rare form of vascular ring, which can easily be confused, on transthoracic echocardiography, with the right-sided aortic arch when there is mirror-imaged branching. Because of its rapid acquisition, computed tomographic angiography with three-dimensional reconstruction has now become the modality of choice for accurate diagnosis of the various forms of double aortic arch. It can be performed without sedation in any age group, including neonates. It provides excellent visualisation of the aortic arch and its branching pattern, thus permitting accurate diagnosis and surgical planning. We present a case series of six children with this rare vascular ring assessed using CT, highlighting their outcomes.

The Impact of Prenatal Diagnosis on Clinical Outcomes of Isolated Vascular Rings From a Statewide Paediatric Cardiology Tertiary Service

BACKGROUND

Vascular rings, including right aortic arch with aberrant left subclavian artery (RAA-ALSCA), double aortic arch (DAA) and pulmonary artery sling (PAS), are congenital anomalies that may cause airway and oesophageal compression. As prenatal detection has improved, literature comparing clinical outcomes of antenatally versus postnatally diagnosed cases continues to emerge. The aim is to define a statewide tertiary paediatric institution's clinical profile and outcomes of prenatal versus postnatally diagnosed isolated vascular rings.

METHOD

A retrospective single-centre review of isolated RAA-ALSCA, DAA and PAS between 1 January 1999 and 31 December 2020 was conducted. Clinical characteristics, surgical and follow-up information were collected. Antenatal and postnatally diagnosed groups were compared.

RESULTS

Out of 123 cases diagnosed with isolated vascular rings, 98 (79.7%) cases had RAA-ALSCA, 21 (17.1%) with DAA, 4 (3.3%) with PAS. The antenatal detection rate was 73.6% in the past decade; 20.3% had a genetic disorder, of which 48% had 22q11.21 microdeletion. Of prenatally diagnosed cases, 31.3% developed symptoms, commonly stridor and dysphagia, at a median age of 2.0 months (IQR 0.0-3.0), compared to a median age of diagnosis for the postnatal cohort of 9 months (IQR 1.0-40.7). Postnatally diagnosed cases were more likely to present with symptoms, primarily respiratory distress, than prenatally diagnosed cases (p=0.006). Fifty-nine (59) cases (50% antenatally diagnosed) required vascular ring division; 6.8% had residual symptoms following surgery.

DISCUSSION

Antenatal diagnosis has improved and leads to better parental awareness and more timely, appropriate intervention. Postnatally diagnosed patients were older, more likely to be symptomatic, underwent more investigations and were commenced on more medications for symptom management prior to diagnosis. One in five cases of isolated vascular ring anomalies carried a genetic diagnosis, which has important implications on prenatal counselling and genetic testing.

Fetal echocardiographic markers to differentiate between a right and double aortic arch

OBJECTIVES

To describe the fetal echocardiographic features of a double aortic arch (DAA) and secondly, to assess the performance of these features to differentiate between a right aortic arch with left duct (RAA-LD) in a blinded cohort of vascular rings.

METHODS

Review of records to identify surgically confirmed cases of DAA diagnosed prenatally from 2014 to 2018 (cohort-A). Prenatal echocardiograms were reviewed and the segments of the aortic arches anterior and posterior to the trachea, aortic isthmuses and the presence/absence of the Z-sign were described. The utility of these markers were assessed in a separate cohort (B) of fetuses with surgically confirmed cases of DAA or RAA-LD.

RESULTS

Cohort-A comprised 34 cases with DAA; there was a dominant RAA in 32/34 (94%) and balanced left aortic arch (LAA) and RAA in two cases. The proximal LAA was seen in 29/34 (85%), distal LAA in 15/34 (44%) and the LAA aortic isthmus in 4/34 (12%). The "Z" configuration was present in 29/34 (85%) cases. The most predictive marker for DAA in cohort-B was the Z-sign (sensitivity: 100%, specificity: 81%).

CONCLUSION

The "Z" sign is a useful differentiator between RAA-LD and DAA. The absence of visualization of the left aortic isthmus does not preclude the presence of a DAA.

How best to describe the pharyngeal arch arteries when the fifth arch does not exist?

In the accompanying article appearing in this issue of the Journal, Prabhu and his colleagues, from Bengalaru in India, describe their experience with patients having a right aortic arch. They discuss the fact that the anomalous arrangements they encountered can all be interpreted on the basis of the hypothetical double arch proposed by Edwards. They point to the fact that interpretation of the developmental changes underscoring the production of the double arch is currently confused by reference to the so-called Rathke diagram, in which six sets of arteries are shown extending through the mesenchyme of the pharyngeal arches. As the authors point out, Graham and his associates have now shown that the alleged fifth set of pharyngeal arches do not exist. Based on our own observations, we endorse this statement. It means that new explanations must now be provided for the lesions previously described on the basis of persistence of the alleged artery of the fifth pharyngeal arch. We have previously claimed to have observed such an artery in a human fetus. We now believe, on the basis of our latest findings, that our earlier observation is better explained on the basis of presence of a collateral channel. We suggest that the so-called "fifth arch arteries" are themselves then best explained either on the basis of existence of such collateral channels, or remodelling of the aortic sac, which is the manifold, during development, that gives rise to the pharyngeal arch arteries.

[Assessment of congenital vascular rings with MDCT on children]

OBJECTIVE

To evaluate the value of MDCT on diagnosis of congenital vascular rings on children.

METHODS

Retrospective analysis on 43 cases of congenital vascular rings, which underwent MDCT during Oct 2008 to Dec 2014 in Beijing Anzhen hospital affiliated to capital medical university. 21 males, 22 females; age from 29 days to 8 years, mean age 1.46 years, 33 cases are not beyond 1 year. All the results were compared with that of the echocardiogram or record of the surgery. The CT data were read and reconstructed with multiplanar reconstruction (MPR), maximum intensity projection (MPR), minimum intensity projection (MinIP), volume rendering (VR). The image quality was evaluated and the diagnostic value and the standard diagnostic program were discussed.

RESULTS

Of 43 cases of vascular rings:there were 6 cases of pulmonary artery sling (13.95%), 9 cases of right aortic arch /aberrant left subclavian artery(20.93%), 18 cases of left aortic arch/aberrant right subclavian artery (41.86%), 10 cases of double aortic arch (23.26%). Forty cases (93.02%) were combined with other cardiovascular or pulmonary malformations. Every malformation was revealed clearly and proved by echocardiogram. Of 3 cases (6.98%) without any other malformation, 2 cases were combined tracheal stenosis. A pulmonary artery sling was proved by surgery; the other 2 cases were double aortic arch. All the images of 43 cases could be reconstructed well. MPR and VR showed the origin, shape, and whole course of vascular rings directly; MinIP and VR could display the shape, width and development of trachea, revealed the relationship between vascular rings, trachea and esophagus. It was important to show and measure the component vascular of the ring. Attention should be paid to the whole course of trachea and esophagus, especially those segments which were close to the ring vascular. The tracheal stenosis as well as intra-cardio anatomy malformations should be measured on MPR images if existed. According to the segmental analysis method, comes the overall final diagnosis. A standard diagnostic program on vascular ring was proposed.

CONCLUSION

MDCT axis images with various 3D post processing methods could reveal the compose of vascular rings and the relationship between vascular rings, trachea and esophagus.

Dilated aberrant right subclavian artery (arteria lusoria), as a rare cause of dysphagia in a patient with abdominal aortic aneurysm

A rare case of a 70 years old man with dysphagia secondary to compression of the oesophagus by dilated aberrant right subclavian artery (ARSA, Arteria lusoria) is presented. Contrast enhanced computed tomography of the mediastinum in our patient revealed this anomalous vessel arising from the aortic arch distal to the left subclavian artery which passed behind the esophagus as it traveled to the right axilla. It had proximal dilated segment compressing the esophagus. The co-existence of this anomaly with aneurysm of abdominal aorta was a unique finding in our patient. ARSA should be taken into account in patients with dysphagia when more common lesions are excluded.

A new variant of aberrant left brachiocephalic trunk in mam: case report and literature review

Importance is placed on aberrant arteries in the radiological and surgical literature. A normal left brachiocephalic trunk is characteristic for the right aortic arch. However, an aberrant left brachiocephalic trunk arising as the last branch of the aortic arch on the left side has not yet been described in the literature. Described here is a new variant of the retro-oesophageal aberrant left brachiocephalic trunk, occasionally observed in a patient during diagnostic investigation or surgical treatment for steno-obstructive involvement of the carotid district. The triple anomaly of the left aortic arch consisted of: 1. the presence of a hypoplastic left brachiocephalic trunk behind the oesophagus, 2. the absence of a brachiocephalic trunk on the right side and 3. separate origins of the arteries on the right side, with the right common artery preceding the right subclavian artery. In front of the trachea an 8-mm prosthetic PTFE was implanted from the proximal segment of the right subclavian artery to the junction of the left common carotid and left subclavian arteries. The author demonstrates the inadequacy of auxiliary investigations to detect aberrant arteries, which may only be identified precisely intra-operatively.

[Urgent cesarean section under combined spinal and epidural anesthesia in a patient with aortitis syndrome]

We report the anesthetic management of a patient with aortitis syndrome using combined spinal and epidural anesthesia. A 28-year-old gravida with aortitis syndrome accompanied by faints was scheduled for an urgent cesarean section. Combined spinal and epidural anesthesia was thought to be better for this case in order to monitor the cerebral circulation by her consciousness level and to reduce the hemodynamic change during surgery as compared to spinal or epidural anesthesia alone. After inserting an epidural catheter at the Th 12/L 1 interspace, spinal anesthesia was performed with 1.5 ml of 0.3% dibucaine at the L 4/L 5 interspace. The level of analgesia was under L 1 with the pinprick method 10 min after the spinal anesthesia. Next, 5 ml of 1.5% mepivacaine was injected through the epidural catheter. The level of analgesia reached to Th 6 without major hemodynamic changes. A healthy 2740 g infant was delivered and she had an uneventful recovery. We conclude that combined spinal and epidural anesthesia is useful in a patient with aortitis syndrome undergoing an urgent cesarean section in order to monitor the cerebral circulation by the consciousness level and to reduce the hemodynamic change.

Takayasu's arteritis

The cause of Takayasu's arteritis is still obscure. However, certain aspects of the disease have been greatly clarified over the past decade. The disease is worldwide in distribution, with no ethnic group being totally free from risk of the condition. The inflammatory and stenotic phases of the disease frequently coexist, and it is important that the condition be diagnosed before it has progressed to the phase of extensive, severe vascular occlusion. Corticosteroid therapy is effective in ameliorating both the more inflammatory aspects of the condition (fever, arthritis, myocarditis) and the hemodynamic problems of vascular stenoses, in some cases allowing return of previously absent pulses. The role of adjunctive cytotoxic therapy is less certain, although there is probably a place for it in cases characterized by corticosteroid resistance or severe consequences of hypercortisolism. Vascular reconstruction is safe and effective once the inflammatory phase of the disease has remitted or been controlled with drug therapy. Prognosis is related to specific disease complications associated with longer duration of disease. Therefore, treatment intervention may modify the natural history of the disease over the long term.

Multiple percutaneous transluminal angioplasties and low dose pulse methotrexate for Takayasu's arteritis

A 20-year-old woman developed left shoulder and arm claudication and angiographic evidence of Takayasu's arteritis. She obtained temporary relief from percutaneous transluminal angioplasties 6 times. Her symptoms were finally controlled with low dose oral pulse methotrexate. This is the first case report of Takayasu's arteritis treated successfully with low-dose pulse methotrexate.

Primary arteritis of the aorta and its branches

Primary arteritis of the aorta and its branches is a single clinicopathological entity affecting one or more segments of the aorta and resulting in a variety of symptom complexes. The prevalence is not known, but it is an important cause of renovascular hypertension in the black population of South Africa. Recently published articles on primary arteritis of the aorta and its branches are reviewed, and an attempt is made to draw conclusions regarding its cause, clinical features and treatment.

Takayasu's arteritis in pregnancy. A report of 4 cases

Four cases of Takayasu's arteritis in association with pregnancy are described. These patients are at high risk of pregnancy hypertension. Measurement of the blood pressure in the arms may be impossible or unreliable and is often more accurately obtained in the legs.

Takayasu's arteritis and pregnancy: a case of deleterious association

The association of pregnancy with Takayasu's arteritis is almost always uneventful. A case with high values of maternal blood pressure (BP) and severe intra-uterine growth retardation (IUGR), submitted to aggressive management with the delivery of a live fetus at 30 weeks, is presented.

A developmental complex including supravalvular stenosis of the aorta and pulmonary trunk

A developmental complex is described characterized by (1) supravalvular stenosis of the aorta and pulmonary trunk, (2) dysplasia of valves and (3) stenosis of ostia of coronary arteries and branches of the aortic arch. From the four cases described, it is evident that not all of the features of the complex need be present in a given case and, when present, some lesions are not of functional significance. The variations underly the potential for differences in the hemodynamic states of affected subjects.