Published online September 25, 2006
PEDIATRICS Vol. 118 No. 5 November 2006, pp. e1336-e1341 (doi:10.1542/peds.2006-1097)
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ARTICLE

Management and Outcomes of Double Aortic Arch in 81 Patients

Khalfan Alsenaidi, MDa, Rebecca Gurofskya, Tara Karamlou, MDb, William G. Williams, MDb and Brian W. McCrindle, MD, MPHa

a Division of Cardiology, Department of Pediatrics
b Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. Double aortic arch is a common form of complete vascular ring, encircling both the trachea and esophagus, resulting in noncardiac morbidity. We sought to describe management and outcomes in a large single institution clinical series.

PATIENTS AND METHODS. We reviewed the medical charts of all of the patients diagnosed with double aortic arch at age <18 years. Data regarding clinical presentation, anatomy, management, and outcomes were abstracted.

RESULTS. We identified 81 patients (67% males) born between 1964 and 2005 and presenting at a median age of 5 months (range: birth to 10.3 years). Respiratory symptoms were present in 91%, including stridor in 77%. Gastrointestinal symptoms were present in 40%, with choking with feeds being most common. The dominant branch of the double aortic arch was right in 72%. Associated cardiac anomalies were present in 18%, with noncardiac anomalies in 7%. Repair was performed in 79 patients at a median age of 6 months. There were 2 deaths after surgical repair with no late deaths, with Kaplan-Meier survival estimates of 96% at 5 years. Postoperative complications included chylothorax in 9%. Only 1 patient required reoperation. The most common symptoms at most recent follow-up were respiratory (54%) followed by gastrointestinal symptoms (6%). Postoperative tracheal stenosis was documented in 14%, with tracheomalacia in 7%. There were no late reoperations and no evidence of aortic arch obstruction.

CONCLUSIONS. Outcomes are excellent after repair of double aortic arch, although persistent respiratory symptoms are frequent and probably associated with previous compression-related maldevelopment of the trachea and major airways.

Key Words: double aortic arch • vascular rings • stridor • congenital cardiac disease • cardiovascular surgery

Abbreviations: DAA—double aortic arch

Double aortic arch (DAA) is a common form of complete vascular ring, a class of congenital anomalies of the aortic arch system, in which the trachea and esophagus are completely encircled by connected segments of the aortic arch and its branches.1,2 The first report of the clinical syndrome of vascular compression produced by a DAA was published by Wolman3 in 1939. Arkin4 first described the radiologic appearance in 6 adults in 1936. The first successful surgical treatment of DAA was reported by Gross5 in 1945 in a 1-year-old boy. The embryonic development of DAA is because of persistence of the fourth arches and dorsal aortas leading to complete vascular ring, encircling both the trachea and esophagus, and causing important respiratory and esophageal symptoms.6–8 The surgical approach at our institution is via a thoracotomy on the side of the descending aorta and to divide the lesser of the 2 arches (nondominant arch) and to divide the ligamentum arteriosum. Although it is rare for the 2 arches to be absolutely equal, in this situation, our approach is to divide the posterior arch to give a more anatomic result. Approach by median sternotomy is favored for patients who require additional cardiac procedures. We sought to review the management and outcomes of a large single-institution series of patients with DAA, with special attention to diagnosis and outcomes at follow-up.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
After approval by the Hospital for Sick Children Research Ethics Board, 81 children <18 years of age diagnosed between 1964 and 2005 with DAA were identified using the Cardiology Database and their medical charts reviewed. Data regarding clinical presentation, age at diagnosis, anatomy, management and outcomes, and follow-up were abstracted. Follow-up symptoms were recorded for early follow-up, which was taken as the immediate period postoperatively before discharge from hospital, and most recent follow-up, which was taken as the date of last clinical follow-up. Data are described as frequencies, medians with ranges, and means with SD as appropriate. Where there are missing data, the number of nonmissing values is given. Overall time-related survival was calculated using Kaplan-Meier estimates. Factors associated with occurrence or persistence of stridor after DAA repair were sought using logistic regression analysis. All of the analyses were performed using SAS 9.0 statistical software (SAS Institute, Inc, Cary, NC) using default settings.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Initial Patient Characteristics
The patient cohort included 81 patients born between 1964 and 2005, 54 (67%) of whom were male. The mean gestational age was 39 ± 3 weeks (n = 54), and the mean weight at birth was 3.1 ± 0.8 kg (n = 37). Onset of symptoms occurred in most patients beginning at birth, ranging up to 3 years of age. Patients presented with respiratory, gastrointestinal, and cardiac symptoms, with respiratory being the most prevalent (Table 1). The most common symptom at presentation was stridor, followed by wheezing. The most common gastrointestinal symptom was choking with feeds. Failure to thrive was a problem in 4 patients (5%).


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  		TABLE 1 Patient Symptoms at Presentation and Follow-up After Repair

 
Associated cardiac anomalies occurred in 14 patients (17%), the most common being a ventricular septal defect in 10 patients (12%), atrial septal defect in 4 patients (5%), patent ductus arteriosus in 3 patients (4%), and tetralogy of Fallot in 3 patients (4%). Associated noncardiac anomalies were rare. Two patients were diagnosed with DiGeorge syndrome, 1 with trisomy 21, and 1 patient with trisomy 18. One patient had associated esophageal atresia, and another patient had a brachial sinus.

Diagnostic Modalities
The most common modality used in the initial evaluation was plain radiography of the chest, performed in 77 patients (95%), and this showed tracheal narrowing in 38 patients (47%) and right arch dominance in 32 patients (40%). However, 20 patients (26%) had normal findings. Initially, bronchoscopy was performed in 25 patients (30%) for investigation of possible laryngeal or tracheal disease as a cause for the symptoms. Esophagography was performed in 60 patients (74%), all of who were noted to have an esophageal indentation, typical for DAA. Diagnostic modalities used included echocardiography in 50 patients (62%), cardiac catheterization in 33 (41%), computed tomography scan in 11 (14%), and MRI in 10 patients (12%). No false-negative results were noted for MRI, computed tomography scan, cardiac catheterization, and esophagography. Determination of arch dominance was fully accurate when determined with MRI or echocardiography, whereas rare misdiagnoses of sided dominance occurred with cardiac catheterization and computed tomography scan.

Initial Repair
A total of 79 patients (98%) underwent surgical repair at a median interval of 1.4 months (range: 3 days to 9 years) after presentation and a median interval of 4.9 months after the onset of symptoms. Repair was achieved mostly via a left lateral thoracotomy in 72 patients (92%) and median sternotomy in 5 patients ([6%] unknown in 2 patients), at a median age of 6 months at repair (range: 15 days to 10 years). Arch dominance, as determined at time of surgery, was right-sided in 56 patients (71%), with the left side of the arch being dominant in 16 (20%) and equal dominance in 7 patients (9%). Repair was not performed in 2 patients. One of these patients was diagnosed after birth by echocardiography after an evaluation for a murmur related to a restrictive ventricular septal defect. He has remained asymptomatic as of the most recent assessment at the age of 8 years. The other patient was diagnosed with trisomy 18 and died after withdrawal of support at age 4 days. Both of these 2 patients were diagnosed to have right arch dominance.

Mortality
A total of 3 patients died at a median age of 1.6 months (range: 4 days to 7 months). One of these patients was the previously mentioned patient with trisomy 18. Two patients died after surgical repair. One patient died 6 days after surgery with respiratory failure secondary to bilateral bronchopneumonia, and the other patient had associated double inlet right ventricle with pulmonary atresia and died just under the age of 2 months after placement of a Blalock Taussig shunt, which subsequently failed. There were no late deaths, with Kaplan-Meier estimates for survival of 99% at 1 week, 97% at 1 month, and 96% at 5 years after admission to our institution.

Postoperative Complications
There were no intraoperative complications. Postoperative complications were infrequent and included chylothorax in 7 patients (9%) and left vocal cord paralysis in 2 patients (3%). Three patients (4%) developed transient hypertension postoperatively.

Reoperation
There was 1 patient who required innominate artery suspension 3.5 weeks after repair of DAA. This patient developed severe stridor and increasing respiratory distress 2 days after the repair and subsequently had respiratory arrest-required reintubation. Computed tomography scan with digital subtraction angiography of the chest showed severe tracheal stenosis with complete extrinsic obstruction of the left main bronchus. Symptoms improved dramatically postoperatively after the suspension.

Intensive Care Unit and Hospital Stay
The median interval between day of surgery and discharge day from the intensive care unit was 2 days (range: 1–34 days), and the median time from surgery to hospital discharge was 8 days (range: 2–69 days). The main reasons for prolonged hospital stay were issues related to complications in 10 patients (13%), noisy breathing and increased secretions in 9 (12%), and establishment of feeds in 7 patients (10%).

Follow-up
Median time between repair and most recent follow-up at the Hospital for Sick Children was 6.5 months (range: 3 days to 16.1 year) at a median age of 1.8 years (range: 1.2 months to 17.5 years). Respiratory symptoms were the most common persistent symptoms on early and most recent follow-up, occurring in 44 (56%) and 43 (54%) patients, respectively (Table 1). The most common respiratory symptom was stridor, which occurred in 43 (54%) at early and 27 patients (34%) at most recent follow-up. The majority (65%) of the 62 patients who presented with stridor continued to have it on early follow-up, but only 25 patients (40%) continued to have it on most recent follow-up. From logistic regression analysis, the only significant factor associated with postrepair stridor at early or most recent follow-up was younger age at repair (Table 2). Patients with versus without stridor also had significantly longer lengths of postrepair stay in the intensive care unit (median: 2 days; range: 1–34 days; versus median: 1 day; range: 1–6 days; P = .04) and overall postrepair hospital stay (median: 8.5 days; range: 2–69 days; versus median: 6 days; range: 3–21 days; P = .03).


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  		TABLE 2 Relationship of Clinical Factors to the Presence of Postoperative Stridor From Univariate Logistic Regression

 
Of the 33 patients who presented with wheezing, 7 (21%) of them continued to have intermittent wheezing on most recent follow-up, and only 2 (29%) of the 7 patients who were diagnosed with asthma before surgery continued to have wheezing at most recent follow-up. Gastrointestinal symptoms were infrequent, affecting 3 patients (4%) at early and 5 patients (6%) at most recent follow-up. Dysphagia was the most common symptom, occurring in 2 patients (3%) at early and 2 (3%) at most recent follow-up.

Different diagnostic modalities were used to evaluate symptomatic patients at follow-up including chest radiography in 19 (24%), bronchoscopy in 12 (15%), esophagography in 10 (13%), computed tomography scan of the chest in 3 (4%), and MRI in 1 patient. Tracheal stenosis was the most common persistent morphologic feature, occurring in 11 patients (14%), with tracheomalacia and esophageal indentation persisting in 6 patients each. Pulmonary function testing performed in 9 patients (11%) was normal in 6 patients, showed an obstructive pattern in 2 patients, and showed restrictive pattern in 1 patient. No symptomatic patient at follow-up required any surgical intervention. Some patients were using bronchodilators intermittently for their respiratory symptoms. There were no late reoperations, and no patient had evidence of aortic arch obstruction.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Anatomy
DAA is the most common clinically recognized form of vascular ring.9–16 Anterior to the trachea, the ascending aorta divides into left and right arches passing to either side of the trachea. As has being described in previous studies, both arches are usually patent, although one is usually larger than the other,10,11,13,16–19 the right arch usually being dominant in 70% of cases.17,19 Previous studies have shown that associated cardiovascular anomalies are uncommon.14,18,19 When present, the associated cardiac defects are usually cyanotic, including tetralogy of Fallot14,19 and transposition of great arteries.20 Other commonly associated cardiac effects include coarctation of the aorta, ventricular septal defect, and patent ductus arteriosus.19,21

Clinical Presentation
DAA manifests earlier than other varieties of vascular rings with symptoms of stridor, dyspnea, cough, and recurrent respiratory infections.10,13,21 In our series, we found that onset of symptoms occurred in most patients at birth, and respiratory symptoms were the most prevalent. In addition to airway symptoms, patients may experience swallowing difficulties related to esophageal compression, which manifests as vomiting and feeding intolerance.11 Life-threatening episodes of reflex apnea with cyanosis have being described.12,22 Six patients in our series presented with life-threatening respiratory arrest requiring resuscitation, and 7 patients presented with apnea.

Diagnosis
In the majority, the diagnosis of DAA was suggested with chest radiography and barium esophagography in symptomatic patients. As has been shown in previous studies, chest radiography often suggests DAA.14,15,23 All of the patients who had barium esophagography in our series showed typical findings of DAA indentation. Echocardiography with Doppler and color flow mapping is an important modality for diagnosis in our center. Echocardiography is a noninvasive, easily available modality allowing complete and accurate anatomic delineation and the exclusion of other major intracardiac pathologies.24,25 Although in the past the diagnosis of DAA has been aided by cardiac catheterization, currently MRI is an important modality used in our center, and it provides excellent preoperative definition with no discrepancies with surgical findings, as has been shown in previous reports.24,26

Surgical Repair
The surgical repair of DAA in our series was performed in the majority of cases via a left thoracotomy approach. Alternatively, a minimally invasive videoscopic approach has been advocated.27 Similar to what has been described in previous studies, the surgical technique at our center is composed of dividing the small atretic arch, which is the left arch in the majority of cases, and also ligation and division of the ductus arteriosus or ligamentum arteriosus, with complete and thorough mobilization of the trachea and esophagus.10–13,28

Follow-up
Varying long-term results have been reported. van Son et al21 reported 37 patients with vascular rings of whom 18 had DAA. All remained asymptomatic at a mean follow-up interval of 18.9 years. Anand et al29 described 44 patients with vascular rings, including 18 patients with DAA. Available follow-up in 14 of these patients at a mean interval of 1542 days showed that 36% had ongoing respiratory symptoms. Chun et al30 described 39 patients with congenital arch anomalies, including 11 with DAA, of whom 47% had mild residual symptoms. In our series, respiratory symptoms were the most common persistent symptoms at most recent follow-up and occurred in 44 patients (56%). Symptoms caused by esophageal compression dramatically improved postoperatively in the majority. Ongoing symptoms were not important enough to intervene surgically. The persistence of symptoms postoperatively can be attributed to tracheomalacia, tracheal stenosis, or both, which are because of maldevelopment of trachea.31 The wide range of follow-up intervals noted in our study may reflect longer follow-up in those with persistence of symptoms, because asymptomatic patients tend to be discharged from care. This potentially may inflate the prevalence of symptoms at most recent follow-up noted in our study.

Our study emphasizes the importance of investigating infants and young children with persistent respiratory and esophageal symptoms for the possibility of having vascular rings, initially with chest radiography and esophagography. If there is any suspicion of a vascular ring, echocardiography is warranted and possibly MRI. Further research studies are needed to develop effective ways of managing patients with persistent ongoing respiratory symptoms with documented morphologic changes to their airways.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
DAA is an important cause of persistent respiratory symptoms in infants and children, and early investigations should be initiated to prevent mortality and morbidity. Findings on chest radiography suspicious of a vascular ring should be correlated with clinical symptoms, and further investigations are warranted. Outcomes are excellent after repair of DAA in our center, with low mortality, although respiratory symptoms are frequent and are likely associated with previous compression-related maldevelopment of the trachea and major airways.


   ACKNOWLEDGMENTS
 
This work was supported in part from the CIBC World Markets Children's Miracle Foundation.


   FOOTNOTES
 
Accepted Jun 5, 2006.

Address correspondence to Brian W. McCrindle, MD, MPH, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: brian.mccrindle{at}sickkids.ca

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Lima JA, Rosenblum BN, Reilly JS, Pennington DG, Nouri-Moghaddam S. Airway obstruction in aortic arch anomalies. Otolaryngol Head Neck Surg. 1983;91 :605 –609[ISI][Medline]
  2. Nikaido H, Riker WL, Idriss FS. Surgical management of "vascular rings". Arch Surg. 1972;105 :327 –333[ISI][Medline]
  3. Wolman IJ. Syndrome of constricting double aortic arch in infancy: report of a case. J Pediatr. 1939;14 :527 –533[CrossRef][ISI]
  4. Arkin A. Double aortic arch with total persistence of the right and isthmux stenosis of the left arch: a new clinical and x-ray picture. Am Heart J. 1936;11 :444 .[CrossRef][ISI]
  5. Gross RE. Surgical relief for tracheal obstruction from a vascular ring. N Engl J Med. 1945;233 :586 –590[ISI]
  6. Mahoney EB, Manning JA. Congenital abnormalities of the aortic arch. Surgery. 1964;55 :1 –14[ISI][Medline]
  7. Tucker BL, Meyer BW, Lindesmith GG, Stiles QR, Jones JC. Congenital aortic vascular ring. Arch Surg. 1969;99 :521 –523[ISI][Medline]
  8. Congdon ED. Transformation of the aortic arch system during the development of the human embryo. Contrib Embryol. 1922;14 :47 –110
  9. Eklof O, Ekstrom G, Eriksson BO, et al. Arterial anomalies causing compression of the trachea and-or the oesophagus. A report of 30 symptomatic cases. Acta Paediatr Scand. 1971;60 :81 –89[ISI][Medline]
  10. Wychulis AR, Kincaid OW, Weidman WH, Danielson GK. Congenital vascular ring: surgical considerations and results of operation. Mayo Clin Proc. 1971;46 :182 –188[ISI][Medline]
  11. Lincoln JC, Deverall PB, Stark J, Aberdeen E, Waterston DJ. Vascular anomalies compressing the oesophagus and trachea. Thorax. 1969;24 :295 –306[ISI][Medline]
  12. Roesler M, De LM, Chrispin A, Stark J. Surgical management of vascular ring. Ann Surg. 1983;197 :139 –146[ISI][Medline]
  13. Arciniegas E, Hakimi M, Hertzler JH, Farooki ZQ, Green EW. Surgical management of congenital vascular rings. J Thorac Cardiovasc Surg. 1979;77 :721 –727[Abstract]
  14. Stewart JR, Kincaid OW, Edwards JE. An Atlas of Vascular Rings and Related Malformation of the Aortic Arch System. Springfield, IL: Charles C. Thomas; 1964
  15. Shuford WH, Sybers RG. The Aortic Arch and Its Malformations With Emphasis on the Angiographic Features. Springfield, MO: Charles C. Thomas; 1974
  16. Binet JP, Langlois J. Aortic arch anomalies in children and infants. Thoracic Cardiovasc Surg. 1977;73 :248 –252
  17. Ekstrom G, Sandblom P. Double aortic arch. Acta Chir Scand. 1951;102 :183 –202[ISI][Medline]
  18. Griswold HE, Jr, Young MD. Double aortic arch; report of two cases and review of the literature. Pediatrics. 1949;4 :751 –768[Abstract/Free Full Text]
  19. Moes CAF. Vascular rings and anomalies of the aortic arch. In: Keith JD, Rowe DR, Vlad P, eds. Heart Disease in Infancy and Childhood. New York, NY: Macmillan; 1978:856–881
  20. Higashino SM, Ruttenberg HD. Double aortic arch associated with complete transposition of the great vessels. Br Heart J. 1968;30 :579 –581[Free Full Text]
  21. van Son JA, Julsrud PR, Hagler DJ, et al. Surgical treatment of vascular rings: the Mayo Clinic experience. Mayo Clin Proc. 1993;68 :1056 –1063[ISI][Medline]
  22. Fearon B, Shortreed R. Tracheobronchial compression by congenital cardiovascular anomalies in children. Syndrome of apnea. Ann Otol Rhinol Laryngol. 1963;72 :949 –969[ISI][Medline]
  23. Bosniak MA. An analysis of some anatomic-roentgenologic aspects of the brachiocephalic vessels. AJR Radium Ther Nucl Med. 1964;91 :1222 –1231
  24. van Son JA, Julsrud PR, Hagler DJ, et al. Imaging strategies for vascular rings. Ann Thorac Surg. 1994;57 :604 –610[Abstract]
  25. Lillehei CW, Colan S. Echocardiography in the preoperative evaluation of vascular rings. J Pediatr Surg. 1992;27 :1118 –1120[CrossRef][ISI][Medline]
  26. Bisset GS, III, Strife JL, Kirks DR, Bailey WW. Vascular rings: MR imaging. AJR Am J Roentgenol. 1987;149 :251 –256[Abstract/Free Full Text]
  27. Koontz CS, Bhatia A, Forbess J, Wulkan ML. Video-assisted thoracoscopic division of vascular rings in pediatric patients. Am Surg. 2005;71 :289 –291[ISI][Medline]
  28. Bertolini A, Pelizza A, Panizzon G, et al. Vascular rings and slings. Diagnosis and surgical treatment of 49 patients. J Cardiovasc Surg (Torino). 1987;28 :301 –312[Medline]
  29. Anand R, Dooley KJ, Williams WH, Vincent RN. Follow-up of surgical correction of vascular anomalies causing tracheobronchial compression. Pediatr Cardiol. 1994;15 :58 –61[ISI][Medline]
  30. Chun K, Colombani PM, Dudgeon DL, Haller JA Jr. Diagnosis and management of congenital vascular rings: a 22-year experience. Ann Thorac Surg. 1992;53 :597 –602[Abstract]
  31. Fleck RJ, Pacharn P, Fricke BL, Ziegler MA, Cotton RT, Donnelly LF. Imaging findings in pediatric patients with persistent airway symptoms after surgery for double aortic arch. AJR Am J Roentgenol. 2002;178 :1275 –1279[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics



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