Surgical repair of cervical aortic arch: An alternative classification scheme based on experience in 35 patients.

OBJECTIVE: Cervical aortic arch (CAA) is rare and difficult to repair. Clinical experience is limited. We report the surgical techniques and midterm outcomes in 35 patients with CAA based on an alternative classification scheme. METHODS: Of 35 patients with CAA, 30 (85.7%) had left-sided aortic arch and 5 had (14.3%) right-sided aortic arch (all 5 had a vascular ring). Mean age was 34.2 ± 13.1 years, 23 were female (65.7%), and 18 were asymptomatic (51.4%). Surgical access and procedure were chosen according to an alternative classification scheme that is based on the presence or absence of vascular ring and relationship of descending aorta to the side of the aortic arch. In the left-sided aortic arch group, aortic arch reconstruction though median sternotomy was performed in 15 patients, and distal arch and descending thoracic aortic replacement via left thoracotomy in 15 patients. In the right-sided aortic arch group, ascending-to-descending aortic bypass was done via median sternotomy in 2 patients and right thoracotomy in 1, and distal arch and descending thoracic aortic replacement via right thoracotomy in 2 patients. RESULTS: Neither death nor spinal cord injury occurred. Left recurrent laryngeal nerve injury, prolonged ventilation, and reexploration for bleeding occurred in 1 each. In 11 patients with coarctation, the upper-lower limb gradient decreased significantly postoperatively (from 34.0 ± 12.7 to 10.2 ± 2.7 mm Hg; P < .01). The diseased aortic segment was excluded in 34 patients, except 1 with residual aneurysm in the proximal descending thoracic aorta. Follow-up was complete in 100% at mean 4.4 ± 2.0 years. No late death, limb ischemia, or stroke occurred. Endovascular repair was performed in 1 patient, and ascending aortic dilation occurred in 1 patient. The residual aorta remained nondilated in 33 patients. Aortic grafts were patent in 100%, with no anastomotic leak or pseudoaneurysm. At 6 years, the incidences of death, aortic events, and event-free survival were 0%, 6.5%, and 93.5%, respectively. CONCLUSIONS: Open repair of CAA can achieve favorable early and midterm outcomes. Surgical accesses and procedures should be chosen based on type of CAA, anatomic variations and associated anomalies. Our alternative categorization scheme of CAA is intuitive and comprehensive, which may facilitate classification and surgical decision making.

Vascular Rings in Adults: Outcome of Surgical Management.

BACKGROUND: Limited data exist on the management of vascular rings (VR) in adults. We reviewed our experience of surgical treatment of these patients. METHODS: All adult patients with VR (n = 65) who underwent VR repair (mean age, 45 ± 16 years; 33 women [51%]) from January 1972 to January 2018 were retrospectively reviewed. Anatomic variants were right arch with aberrant left subclavian artery (SA) and Kommerell diverticulum (KD) in 22 (34%), left arch with aberrant right SA and KD in 20 (31%), double aortic arch in 12 (18%), right arch with mirror imaging and persistent ligamentum off KD in 7 (11%), and others in 4 (6%). Indications for operation included dysphagia in 43 (63%), respiratory symptoms in 28 (43%), aneurysmal KD in 12 (18%), and dissection/rupture in 7 (11%). RESULTS: KD was found in 51 patients (78%). The surgical approach included left thoracotomy in 50 (77%), right thoracotomy in 7 (11%), sternotomy in 5 (8%), and hybrid repair in 3 (5%). A 2-stage repair with carotid-SA transposition, followed by transthoracic KD excision, was done in 51% of aberrant SA (n = 23). There was 1 early death. Morbidity included recurrent laryngeal nerve injury in 5 (8%) and chylothorax in 3 (5%). Symptomatic improvement occurred in 97%. Survival was 96.1%, 85.0%, and 73.4% at 1, 5, and 10 years, respectively. Dysphagia recurred in 9 (14%), which included 7 (11%) with esophageal dysmotility. CONCLUSIONS: Repair of VR in adults can be performed safely. Dysphagia is the most common symptom and improves in most after repair. Excision of the KD and aberrant vessel is the preferred approach to prevent acute aortic events or recurrent symptoms. Early operation should be considered with esophageal compression to avoid late dysmotility.

Vascular ring: Early and long-term mortality and morbidity after surgical repair.

BACKGROUND: Vascular ring is a rare cause of recurrent respiratory infections, dysphagia and stridor. Surgical repair is considered safe but the long-term outcomes are unclear. The purpose of this study was to investigate the mortality and morbidity following vascular ring surgery in a single institution. MATERIALS AND METHODS: This retrospective study covers operations done at Aarhus University Hospital, Denmark between October 1983 and May 2015. Medical records were reviewed focusing on early complications and long-term complaints up to September 2017. RESULTS: A total of 23 patients with median age of 1.4 years (range 0.008-64 years) were operated for vascular ring. Median follow-up was 6.8 years (range 2.4-34 years). Presenting symptoms were stridor (52%), dysphagia or vomiting (52%) and recurrent respiratory infections (48%). There were no early or late deaths. Three months postoperatively, 59% reported no respiratory complaints and 50% reported normal eating habits. Long term, only 14% had no complaints. In particular, asthma (36%), persistent stridor (18%) and recurrent respiratory infections (32%) were frequent. A high number of patients developed mental illness (27%). CONCLUSION: Surgery for vascular ring can be performed with low early and long-term mortality. Despite good three months outcome, the majority of patients had long-term respiratory issues. Oesophageal morbidity was low. LEVEL-OF-EVIDENCE: 2B.

Outcomes following thoracotomy or thoracoscopic vascular ring division in children and young adults.

OBJECTIVE: To determine the short- and intermediate-term outcomes following vascular ring division by video-assisted thoracoscopic (VATS) or thoracotomy approach. METHODS: This study is a retrospective review of patients with double aortic arch or right aortic arch with aberrant left subclavian artery and left ligamentum (RAA with LSCA/LL) who underwent division via left thoracotomy or VATS approach at a single institution. Outcome measures included operation duration (OR time), hospital length of stay (LOS), postoperative complications, and freedom from reintervention. RESULTS: A total of 200 patients underwent vascular ring division by VATS (n = 115) or thoracotomy (n = 85). Of 200 patients, 125 (56%) displayed respiratory symptoms at presentation, 29 (11%) displayed digestive tract symptoms, and 41 (32%) displayed both. Median follow-up was 2.1 years (interquartile range: 1 month to 7.1 years). Overall cohort mortality was 1 (0.5%) of 200 at 11 years after surgery. Fifteen (7.5%) experienced immediate postoperative complications. At follow-up visit within 1 month after surgery, 92 (74%) of 125 patients reported improvement in symptoms. Freedom from reintervention was 96% and 90% at 5 years and 10 years, respectively. Among patients with RAA with LSCA/LL (n = 113), VATS was associated with shorter LOS compared with thoracotomy (1.2 vs 3.4 days; P < .001), but rates of complications were not significantly different (9% vs 4%, P = .68). CONCLUSIONS: Vascular ring division by either thoracotomy or VATS can be performed with low rates of complication and need for reintervention. Compared with thoracotomy, VATS is associated with shorter operative duration and hospital LOS among patients with RAA with LSCA/LL.