Rare Case of Vascular Sling With Left Main Bronchus Compression

This 2-year-old girl was evaluated for a recurrent respiratory tract infection and palpitations. She was further evaluated and diagnosed with a large secundum atrial septal defect (ASD) with dilated right atrium (RA) and right ventricle. However, the left pulmonary artery was not visible on the echocardiogram. A chest computed tomography scan showed that the left pulmonary artery (LPA) arose from the right pulmonary artery (RPA). The LPA traveled between the trachea and esophagus, causing a vascular sling and also compressing the left main bronchial stump. There was no evidence of tracheal stenosis or complete tracheal ring. In view of the vascular sling, she was taken up for surgery.

After opening the chest, the vascular sling was identified. The RPA was further dissected. The LPA and its origin from the RPA was identified. The LPA was dissected up to the trachea. A patent ductus arteriosus (PDA) was identified and divided. Cardiopulmonary bypass was established with aortic and bicaval cannulation. The patient was cooled down to 32 degrees. The LPA was disconnected from the RPA, and the RPA stump was sutured. The LPA was further mobilized between the trachea and esophagus, and it was brought anterior to the left main bronchus after carefully dissecting from the posterior wall of trachea and left main bronchus. The aorta was cross-clamped. The heart was arrested with del Nido cardioplegia. After snaring the superior and inferior vena cava, the RA was opened. The atrial septal defect was visualized and closed with a large patch of treated pericardium. After deairing the left side of the heart, the cross-clamp was released. The heart picked up in sinus rhythm. Excessive length was removed from the LPA. A side-biting clamp was applied on the main pulmonary artery (MPA) at the site of the PDA. A nice opening was made after removing all the ductal tissue. The LPA was reimplanted into the MPA using 6-0 polydioxanone sutures.

The patient was rewarmed and weaned from cardiopulmonary bypass. Transesophageal echocardiogram showed no residual ASD and good biventricular function. On-table bronchoscopy showed a wide opened left main bronchus. The authors decided not to intervene on left main bronchus. The child had an uneventful postoperative period and was sent home on the fourth postoperative day. The patient had an uneventful recovery and was doing well at the end of a six month follow-up.

Suggested Reading

1. Backer CL, Mavroudis C, Dunham ME, Holinger LD. Pulmonary artery sling: results with median sternotomy, cardiopulmonary bypass, and reimplantation. Ann Thorac Surg. 1999;67(6):1738-1745.
2. Fiore AC, Brown JW, Weber TR, Turrentine MW. Surgical treatment of pulmonary artery sling and tracheal stenosis. Ann Thorac Surg. 2005;79(1):38-46.