Anterior Translocation of the Circumflex Aortic Arch

This video demonstrates an anterior translocation of the circumflex aortic arch for the management of esophageal compression.

A 9-year-old boy diagnosed with a 22q11 deletion had a longstanding history of swallowing difficulty. His parents noted that he always had to have a sip of fluid for solid ingestion. The rest of his medical history was unremarkable.

An echocardiogram showed cervical right aortic arch with a probable aberrant left subclavian artery. Videofluoroscopic swallowing exam and upper gastrointestinal endoscopy documented the partial occlusion of the proximal esophagus with extrinsic compression. Computed tomography angiogram was done to further delineate the anatomy. It showed right-sided aortic arch which was cervical in location, extending to the level of the clavicles. The first branch of the arch was the left common carotid artery, followed by the right common carotid artery. The third vessel coming off the arch was the right subclavian artery, followed by the aberrant left subclavian artery. The posterior arch and descending thoracic aorta crossed the midline and descended on the left, consistent with a circumflex arch. The trachea and bronchi were widely patent.

The patient was put forward for aortic arch reconstruction in the form of dividing and translocating this circumflex arch anteriorly. It could be argued that division of the ligamentum, transection of the aberrant left subclavian artery, and reimplantation of this vessel through thoracotomy would have been preferred. Although division of the ligamentum releases the vascular ring as a less extensive approach, it does not relieve the compression caused by the superiorly-located aortic arch crossing from right to left.¹ Hence, most of those patients develop recurrent symptoms following this operation.² The authors had performed three anterior translocation of circumflex arch operations in their unit. Two of those operations were done on patients who had previously undergone ligamentum division and developed recurrent symptoms. Therefore, the authors specifically preferred translocating the aortic arch anteriorly instead of the thoracotomy approach in this patient.

Following the midline sternotomy, the pericardium was opened. The distal ascending aorta and the proximal arch were dissected and mobilized. The first two branches of the arch were the left and right common carotid arteries, as shown in the video. Heparin was given, and the proximal arch and the right atrium were cannulated for cardiopulmonary bypass. The patient was commenced on bypass and cooled down to 20 degrees Celsius. Whilst cooling, the whole arch, including the main branches, was mobilized. Tourniquets were placed around the head and neck vessels for selective antegrade cerebral perfusion during circulatory arrest. The arterial ligament was doubly ligated and divided. The descending aorta was mobilized extensively, and the left and right recurrent laryngeal nerves were visualized and preserved. A cardioplegia needle was placed in the proximal ascending aorta. When the patient’s temperature dropped down to 20 degrees Celsius, the distal ascending aorta was cross-clamped. Cold blood cardioplegia was infused through the aortic root. Following that, the pump was stopped, the aortic cannula was advanced into the right common carotid artery, and all the head vessels were snared down. The cross-clamp was repositioned to the descending aorta.

The circumflex aortic arch was divided at the right side of the ascending aorta, just distal to the right subclavian artery, and the stump was oversewn with a 5-0 Prolene® suture under circulatory arrest. The circumflex arch was dissected from the surrounding attachments and translocated anteriorly to the left side of the ascending aorta. Neurovascular structures were left pristine. Following that, selective antegrade cerebral perfusion with 50 mL/kg/min was initiated. An aortotomy was made on the left side of the ascending aorta and extended into the left common carotid artery. The anteriorly-translocated aortic arch was anastomosed to the ascending aorta with 5-0 Prolene® sutures in an end-to-side fashion. Having completed the anastomosis, all the snares and the clamps were removed. The arterial cannula was repositioned into the aortic arch and the flow was increased to full flow. The patient was fully rewarmed.

The stump of the previous circumflex arch was pushed away with an aortopexy suture to preclude any residual compression on the trachea and esophagus. The authors preferred a 5-0 pledgeted Prolene® stitch to do the aortopexy in that area.

The patient came off cardiopulmonary bypass with good cardiac function and hemodynamics. There was no gradient measured between the upper and lower limbs via arterial line tracing. Cardiopulmonary bypass and cross-clamp times were 143 and 30 minutes, respectively, and the circulation was arrested for 10 minutes. The patient recovered well after the operation. He was extubated on the first postoperative day and discharged on the fifth day with normal swallowing.

References

1. Russell HM, Rastatter JC, Backer CL. The aortic uncrossing procedure for circumflex aorta. Oper Tech Thorac Cardiovasc Surg. 2013;18(1):15-31.
2. Backer CL, Mongé MC, Russell HM, Popescu AR, Rastatter JC, Costello JM. Reoperation after vascular ring repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2014;17(1):48-55.