Aortic uncrossing is indicated for symptomatic patients with a circumflex aorta causing significant tracheoesophageal compression.
Case presentation
The authors present a two-year-old child (12.4 kg) with dysphagia who was diagnosed with a circumflex aorta consisting of a right aortic arch, a left descending thoracic aorta, and a ligamentum arteriosum that formed a complete vascular ring.
Operative Steps
A left posterolateral thoracotomy through the third intercostal space was performed. The descending thoracic aorta, retroesophageal arch, bilateral subclavian arteries, and ligamentum arteriosum were dissected and looped. Following the division of the ligamentum arteriosum and the mobilization of the descending thoracic aorta, the patient was repositioned supine, and a median sternotomy was performed. After initiation of cardiopulmonary bypass and cooling to 22°C, selective antegrade cerebral perfusion was established. The aortic arch was divided distal to the left subclavian artery. The descending thoracic aorta was then translocated anterior to the trachea and esophagus and anastomosed to the proximal arch without patch augmentation.
Preference Card
A standard pediatric cardiopulmonary bypass setup was used, along with vessel loops for the arch vessels and descending thoracic aorta, selective antegrade cerebral perfusion, and polypropylene sutures.
Tips and Pitfalls
Consider a circumflex aorta in children presenting with dysphagia or respiratory symptoms that appear disproportionate to the associated cardiac findings. Extensive mobilization of the descending thoracic aorta is essential to achieve a tension-free anastomosis. An anterior patch may be used during reconstruction to avoid tension or kinking of the anastomosis.
Outcomes
Postoperative echocardiography demonstrated a patent reconstructed arch with laminar flow. The postoperative course was uncomplicated. The patient was extubated and weaned from inotropic support on postoperative day one and discharged home on postoperative day six.
References
- Haranal M, Srimurugan B, Sivalingam S. Circumflex aorta: an uncharted territory. Asian Cardiovasc Thorac Ann. 2022;30(2):217-225. doi:10.1177/02184923211015092. PMID: 33957784.
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