Andersons pediatric cardiology 1272
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archrelativetothesestructures.Whensymptomsoccur,simpleligationand
divisionoftheligamentumarteriosumisnotsufficienttorelievesymptoms
despitethismaneuverdividingthering.115Ligationanddivisionofthe
ligamentumarteriosumalonedoesnotchangethecompressiveeffectofthe
retroesophagealaorticarch.Symptomsincludethosecommonlyseenwith
completerings:noisybreathing,dysphagia,andfrequentupperrespiratorytract
infections.115The“aorticuncrossingprocedure,”originallydescribedbyPlanche
andLacour-Gayet,istheprocedureofchoiceformanagingthisaorticanomaly
inpatientswithabiventricularheart(Fig.47.24).116Theaorticuncrossing
procedureinvolvesestablishmentofcardiopulmonarybypassbymedian
sternotomy.Theligamentumarteriosumisligatedanddivided.Usingdeep
hypothermiaandabriefperiodofcirculatoryarrest,theaortaistransecteddistal
tothebranchpointoftherightsubclavianartery.Thedescendingaortais
mobilizedandbroughtanteriortothetracheaandesophagus.Anend-to-side
anastomosisofthedescendingaortatoascendingaortaisperformed.115,116The
anteriorpositionoftheneoaorticarchrelievestheposteriorcompressiononthe
tracheaandesophagus.Amodificationoftheaorticuncrossingprocedurehas
beendescribedforcomplexuniventricularcongenitalheartdiseasewitha
hypoplasticandcircumflexaorticarch(Fig.47.25).117
FIG.47.24 Aorticuncrossingprocedureforacircumflexretroesophageal
aorticarch.
FIG.47.25 Themodifiedaorticuncrossingprocedureforcomplex
univentricularcongenitalheartdiseasewithahypoplasticascendingaorta
andhypoplasticretroesophagealcircumflexaorticarch.DKS,DamusKaye-Stansel;IVC,inferiorvenacava;SVC,superiorvenacava.
CervicalAorticArch
Aclassificationschemeofthecervicalaortawasproposedin1975.118TypeA
hasacontralateraldescendingaortawithabsenceofonecommoncarotidartery.
TypeBhasacontralateraldescendingaortawithbothcommoncarotidarteries.
TypeChasacontralateraldescendingaortawithabicarotidtrunk.TypeDhas
anipsilateraldescendingaortawithnormalbrachiocephalicbranching.TypeEis
arightaorticarchwitharight-sideddescendingaorta.118Completevascular
ringsinthisrareaorticarchvariantoccurinthetypeswithacontralateral
descendingaorta.Whenpatientsdevelopsymptomsfromtrachealand
esophagealcompression,theycanpresentwitheitheraright35orleftcervical
aorticarch.119,120Forexample,a1-year-oldpatientwithDiGeorgesyndrome
presentedwithapnea-bradycardiaspellsandaspirationoffeeds.Anesophagram
