Reducing the Trauma of Vascular Ring Division

Redmond P. Burke, M.D. Chief, Division of Cardiovascular Surg The Congenital Heart Institute Miami Children s Hospital 2011

Surgical History of Vascular Ring
First surgical division by Dr Robert Gross At Boston Children s Hospital in 1945

First Video-assisted thoracoscopic vascular ring division by Burke at Boston Children s Hospital in 1993, 48 years later

Fig. 4. Pitx2c in remodeling the great vessels and outflow tract. (A) Remodeling of aortic arch arteries and derivation of mature aortic arch vessels (adapted from Moore, 1982). Cathy Walters E-mail: cathy@biologists.com

Clinical Presentation may be variable: breathing problems, swallowing problems, both, or nothing.

This child was diagnosed when he swallowed a coin.

Barium Swallow

Remains the Gold Standard for diagnostic tests.

Surgical Approach: Thoracotomy vs Video Assisted Thoracoscopic Surgery (VATS)

Our Surgical Approach: Reduce cumulative patient trauma with a video assisted thoracoscopic approach to avoid a large chest incision

How we Definine The Perfect Approach for Vascular Ring Division 
  

No breast trauma No muscle trauma No nerve trauma Put the surgeon close to the lesion, allowing precise diagnosis, dissection, suturing, and vascular control

Double Aortic Arch Dissection

Completed Division
Surgical note: We precisely cut the scar tissue on the surface of the esophagus

Video of Vascular ring division: Right Aortic Arch, aberrant left subclavian, left ligamentum

Surgical Techniques for Ring Sling Complex
Surgical philosophy: Repair the trachea and the left pulmonary artery in the least traumatic way. Follow the LPA closely.

Innominate Suspension: for patients with innominate artery compression of the trachea
Surgical Options: Anterior tacking of the innominate artery to the sternum, or detachment and reimplantation of innominate artery

Potential Surgical Complications after vascular ring division 


Recurrent or Phrenic Nerve injury Persistent vascular ring 

Caused by the surgeon missing one element of a double aortic arch Caused by damage to the Thoracic duct. Caused by injury to the aortic arch vessels. It is fairly common for patients to have long term reactive airways (like asthma) even after ring division. We think this might justify earlier intervention on asymptomatic patients, to avoid this long term injury to the airway. 

 

Chylothorax: 

Hemorrhage 

Persistent Symptoms 


Surgical Outcomes 
     

Miami Children s Experience N= 24, DAA 14, RAA/ALSCA 8, PA sling 2 Age Median 2 months, range 8 days to 42 years Weight Median 6.4 kg, range 2.5 kg to 78 kg Hospital Stay Median 5 days, range 1 to 27 days Mortality: zero Morbidity 


Major: none Minor: Atelectasis 3/24

Thank You