Andersons pediatric cardiology 1273
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showedaposteriorindentationoftheupperone-thirdoftheesophagusatthe
leveloftheaorticarch.Asdemonstratedinthethree-dimensional
reconstructionsofacomputedtomographyangiogram(Fig.47.26A–B),this
childhasaleftaorticarchwitharightligamentumarteriosumandaright-sided
descendingthoracicaorta.Thesurgicalapproachisdictatedbythepositionof
thedescendingthoracicaorta.Inthiscaseararerightthoracotomytodividethe
completevascularringwasused.Forsomecases,ligationanddivisionof
ligamentumarteriosumissufficienttorelievethesymptoms.Morecomplex
repairshavebeenreported,includingresectionofadiverticulumofKommerell
withreplantationofanaberrantleftsubclavianarteryintotheleftcommon
carotidartery,38extraanatomicbypass,121andstagedbiventricularrepairfor
hypoplasticcervicalarches.122
FIG.47.26 (A)CTangiogramofaleftaorticarch,right-sideddescending
thoracicaorta,andright-sidedligamentumarteriosum(anteroposterior
three-dimensionalreconstruction).(B)Sameimage,superiorview.
Outcomes
Therehasbeenalonghistoryofsuccessfulsurgicalrepairforvascularring
anomalieswithminimalsurgicalmortality.123–126Thatsuccesshasbeen
sustainedintothecurrentsurgicalerawheretheoperativemortalityapproaches
zero.9,127Morbidityseemstobethedrivingforceintheshort-andlong-term
successofsurgicalrepairfortheseanomalies.128Commonpostoperativeissues
includetheneedfortracheostomyandrecurrentlaryngealnervepalsy,128
chylothorax,4andrecurrenceofsymptoms.129Theincidenceofrecurrent
respiratorysymptomshasbeenreportedtobeashighas54%,whereasrecurrent
gastrointestinalsymptomsaremuchlesscommon.9Themostcommon
indicationsforsurgicalreinterventionforrecurrentrespiratorysymptomshave
beenanunresectedKommerelldiverticulumatinitialsurgicalintervention,a
circumflexaorta,residualscar,andpersistenttracheomalacia.130Theseanatomic
indicationsforsurgicalreinterventioncanbemanagedrespectivelyby
diverticulumresectionwithleftsubclavianarterytransfer,theaorticuncrossing
procedure,resectionofresidualscartissue,andaortopexy.130
