IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly
With Dr. Steve Rothenberg
Chapter 1 of 4 · Case-Based Learning
Patient anatomy
Patient presentation and vascular anatomy
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What the experts said
The patient is a 43-day-old male born at 36 weeks gestation with multiple congenital anomalies consistent with VACTERL association.
Echocardiogram revealed a vascular ring comprised of a right-sided dominant double aortic arch with left carotid and subclavian arteries arising from the right arch.
An atretic left proximal arch was present between the origin of the left subclavian artery and left-sided patent ductus arteriosus.
A right dorsalis pedis arterial line was obtained prior to the procedure.
A blood pressure cuff was placed on the right arm and pulse oximeters on upper and lower extremities for monitoring.
A bronchial blocker was placed in the left main bronchus for single lung ventilation.
The patient was placed in right lateral decubitus position for the thoracoscopic approach.
Three ports were used: a 4-millimeter camera port in the fifth intercostal space posterior to the scapula tip, and two 3-millimeter working ports in the seventh intercostal space posterior axillary line and third intercostal space inferior to the axilla.
A pleural flap was elevated over the descending thoracic aorta and extended superiorly to the thoracic inlet and along the left subclavian artery.
Both the left ductus arteriosus and left recurrent laryngeal nerve were identified during dissection.
A test clamp on the ductus arteriosus was performed to ensure stability of vital signs prior to sealing and transecting.
The left aortic arch was bluntly dissected and encircled, with the atretic segment at the level of the left subclavian artery takeoff visualized.
A test clamp was performed on the atretic segment of the left aortic arch with unchanged blood pressures and saturations.
The posterior port was upsized to a 5-millimeter trocar to accommodate the stapler.
The left aortic arch was transected using a 5-millimeter stapler, releasing the vascular ring.
Division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5-millimeter stapler.
There were no intraoperative complications.
The patient returned to the NICU intubated and was extubated on postoperative day one.