Vascular Ring in Adult

Author: Edward Verrier, MD
Institution: University of Washington
Date Reviewed: March 2014
Learning Domain: Adult Cardiac Surgery
Learning Objective: Vascular Ring; Tracheal/Esophageal Compression
PowerPoint File: File Vascular_Ring.pptx

 

Presentation

  • 22 y/o with Increasing SOB/DOE
  • Decreased exercise intolerance for 2 years 
    • Can’t keep up with Marine recruits
  • PMH:
    • Palpitations
    • Mild scoliosis

 

History and Exam

Pertinent Physical Exam

  • BP 126/81, Pulse 78, Temp 36.5, 77.6 kg
  • Lungs clear bilaterally
  • Heart rate regular with no M, G, H, T
  • Full pulses, no clubbing

Labs

  • All labs normal

Medications

  • No medications

 

Chest X-Ray

 

Esophagram

 

MRI

  

MRI Results

  • Abnormal double arch  
  • Right-sided primary arch 
  • Atretic left-sided arch 
    • Gives off the left subclavian and left carotids
  • Vascular ring with 2 diverticula, 
    • One coming off the right-sided aortic arch
  • Thin band that appears to encircle the trachea and esophagus.  
  • Smaller diverticulum on the carotid side.

 

Outcomes

  • Left thoracotomy 
    • Double lumen endotracheal tube
  • Resection of Ligamentum Arteriosus
  • Vascular stapling Left carotid aneurysm
  • Partial side clamp Aorta
  • Resection of Kommerall Diverticulum
  • Discharge POD 4
  • Asymptomatic at 1 year

 

Literature

  • JA van Son et al: Burkhard Kommerell and Kommmerall’s Diverticulum. Tex Heart Inst J 29: 2002
  • Backer CL et al: Resection of Kommerell’s Diverticulum and L subclavian artery transfer. EJCTS 22: 2002

  

Learning Points

  • Abnormalities of the Aortic Arch are rare but can present in adults
  • Compression on trachea or esophagus is common
  • Simple transection of the ligamentum is often inadequate
  • Each case must be individualized in operative approach