Ann Thorac Surg 2003;75:1959-1960
© 2003 The Society of Thoracic Surgeons
Case report
Vascular ring causing tracheal compression in an adult patient
Andreas Greiner, MDa*,
Reinhold Perkmann, MDa,
Michael Rieger, MDb,
Beate Neuhauser, MDa,
Gustav Fraedrich, MDa
a Departments of Vascular Surgery, Innsbruck, Austria
b Radiology, University Hospital, Innsbruck, Austria
Accepted for publication November 14, 2002.
* Address reprint requests to Dr Greiner, Department of Vascular Surgery, Innsbruck University Hospital, Anichstr 35, 6020 Innsbruck, Austria
e-mail: andreas.greiner{at}uibk.ac.at
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Abstract
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A 65-year-old woman was referred for evaluation because of a few years’ history of inspiratory obstruction without dysphagia. A right aortic arch with mirror image bracheocephalic vessels narrowing the trachea was considered to be the reason for the dyspnea. Immediate decompression of the trachea and symptomatic relief was achieved through surgical treatment.
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Introduction
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Anatomical abnormalities of the aortic arch may cause clinical symptoms such as respiratory insufficiency and dysphagia [1–4]. They are well documented in infants and children; however, the occurrence among adults is less than 0.01% [2].
We are reporting a 65-year-old woman admitted for evaluation of a 5-year history of inspiratory obstruction, with an increase of symptoms in the latter period. There was no serious disease in her history.
After the chest roentgenogram had shown a right-sided aortic arch, a high-resolution, multislice computed tomographic (CT) scan with volume-rendering reconstruction was performed and revealed a partial vascular ring narrowing the trachea significantly. The following branches were arising from the right aortic arch (Fig 1):
left innominate artery, right common carotid artery, and right subclavian artery. The left innominate artery gave rise to a left common carotid artery and left subclavian artery. Also, a diverticulum of the innominate artery existed. The partial vascular ring, narrowing the trachea, was formed by the right-sided aortic arch and the left-sided innominate artery. Both the trachea and the esophagus were dislocated to a ventral position by the descending aorta. The most narrowed lumen of the trachea was 7 mm in diameter.
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Fig 1. Right aortic arch with mirror-image bracheocephalic vessels. (LCCA = left common carotid artery; LIA = left innominate artery; LPA = left pulmonary artery); LSA = left subclavian artery; RCCA = right common carotid artery; RSA = right subclavian artery.)
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Surgery was performed through a median sternotomy extended to the left supraclavicular region. It appeared that the ectatic left-sided innominate artery pressed the trachea against the distal part of the aortic arch. The ligamentum arteriosum originated from the innominate artery. There was no retroesophageal component. The left-sided innominate artery showed signs of a moderate arteriosclerosis and was separated from the aortic arch. A 10-mm Dacron graft was interposed between ascending aorta and the left subclavian artery, with the left common carotid artery being anastomosed into the prosthesis (Fig 2)
. Material of the innominate artery was sent for histological evaluation and showed typical arteriosclerosis.
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Fig 2. Results after amputation of the left innominate artery from the aortic arch and interposition of a Dacron graft between the ascending aorta and left subclavian artery, with the left common carotid artery being anastomosed into the prothesis. (LCCA = left common carotid artery; LPA = left pulmonary artery; LSA = left subclavian artery; RCCA = right common carotid artery; RSA = right subclavian artery.)
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Immediately after the procedure, the patient did well and experienced significantly improved breathing. Six months later, the patient was still without any complaints regarding respiratory symptoms. A high-resolution multislice CT scan with volume-rendering reconstruction was performed and showed undisturbed arterial and tracheal patency. The vessel anastomoses were intact without signs of leakage. Neither the clinical nor the radiological follow-up identified any signs of tracheomalacia. There was no difference in the spirometry before and after the surgical procedure, which showed a moderate inspiratory obstruction.
A vascular ring is defined as an anomaly of the great arteries (aortic arch and its branches) that compresses the trachea or esophagus [6]. They are very rare and become symptomatic usually in infancy or in early childhood [3]. The most common vascular ring in adults consists of double aortic arch followed by right aortic arch with aberrant left subclavian artery and ligamentum arteriosum. Dysphagia is reported to be the most common symptom of vascular rings in adults [4]. Different pathophysiological mechanisms causing respiratory symptoms in adults are discussed. The vascular ring may become more constrictive in adults by degenerate changes in the thorax, vertebrae, and mediastinum [5]. In this case, the natural course of arteriosclerosis stiffened the texture of the vascular ring and caused enlarging of the aorta. It seems that this was the reason for the late development of respiratory symptoms. It is well documented in the literature that arterial pressure is the predominant force, which leads to dilatation of the aorta. During exercise, the diameter of the ascending aorta increases by approximately 1 mm for each 15-mm Hg increase in arterial pressure [7, 8]. In our case, the patient avoided physical exertion from youth on. Hence, physical inactivity of our patient may be one more reason for the late detection of her symptoms.
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Comment
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Spirometry is neither specific nor sensitive as a diagnostic tool for surgical evaluation, and therefore not valid for indication of surgical therapy for vascular rings [4]. Indication for surgical treatment should be based on clinical symptoms and imaging diagnostic.
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References
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- Bossert T., van Son J.A., Autschbach R., Mohr F.W. Resection of a right atrial metastatic melanoma with unknown origin of primary tumor. Eur J Cardiothorac Surg 1999;15:373-375.[Abstract/Free Full Text]
- Bialowas J., Hreczecha J., Grzybiak M. Right-sided aortic arch. Folia Morphol (Warsz) 2000;59:211-216.
- Bakker D.A., Berger R.M., Witsenburg M., Bogers A.J. Vascular rings: a rare cause of common respiratory symptoms. Acta Paediatr 1999;88:947-952.[Medline]
- Grathwohl K.W., Afifi A.Y., Dillard T.A., Olson J.P., Heric B.R. Vascular rings of the thoracic aorta in adults. Am Surg 1999;65:1077-1083.[Medline]
- Wright P.M., Alexander J.P. Acute airway obstruction, hypertension and kyphoscoliosis. Anaesthesia 1991;46:119-121.[Medline]
- Kirklin J.W. Vascular ring and sling. In: Kirklin J.W., Barratt-Boyes B.G., eds. Cardiac surgery. New York: Churchill Livingstone, 1993:1365-1382.
- Isnard R.N., Pannier B.M., Laurent S., London G.M., Diebold B., Safar M.E. Pulsatile diameter and elastic modulus of the aortic arch in essential hypertension: a noninvasive study. J Am Coll Cardiol 1989;13:399-405.[Abstract]
- Merillon J.P., Motte G., Fruchaud J., Masquet C., Gourgon R. Evaluation of the elasticity and characteristic impedance of the ascending aorta in man. Cardiovasc Res 1978;12:401-406.[Medline]
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Abstract
Introduction
