Double Aortic Arch Treatment & Management
- Author: Doff B McElhinney, MD; Chief Editor: Stuart Berger, MD more...
Medical care prior to surgical repair of double aortic arch depends on the clinical presentation. In most patients, only supportive care is required.
Catheter interventions are not used in the management of double aortic arch.
Aside from analgesic medications, pharmacologic therapy is not usually required after removal from mechanical ventilation. Relief from the pain of the thoracotomy incision may be achieved with age-appropriate narcotic and nonsteroidal anti-inflammatory medications.
Further inpatient care
Routine postthoracotomy care is provided following repair of double aortic arch.
Patients are removed from mechanical ventilation as soon as possible, and tube thoracostomy usually is discontinued on the first postoperative day.
The remainder of the inpatient stay is focused on determining and managing any residual symptomatology, providing sufficient enteral nutrition, transitioning the patient to enteral analgesics, and educating the parents.
In patients with residual or recurrent obstruction of the airways, aortopexy may relieve the compression and associated symptoms.
Unless specific associated anomalies or problems are identified, consultations usually are not necessary. As noted above, band 22q11 deletion is present in a substantial proportion of patients with double aortic arch.
Consultation with a geneticist is indicated in patients with other characteristic features of the band 22q11 deletion syndrome and may be appropriate in young infants, in whom typical features of the syndrome may not yet be evident.
After postoperative stabilization in the intensive care unit and removal from mechanical ventilatory support, the patient may be transferred to the regular inpatient care area for advancement of feedings and additional postoperative care.
Surgical division of the vascular ring is indicated in any patient with symptoms of airway or esophageal compression and in patients undergoing surgery for repair of associated cardiovascular or thoracic anomalies.
The fundamental principle of surgical management of double aortic arch is division of the ring to relieve compression of the trachea and esophagus. In general, this is achieved by dividing the minor arch through an ipsilateral thoracotomy. Note the following:
When the minor arch is atretic, the atretic segment is ligated or clipped and then divided. When the minor arch is patent, it is usually ligated and divided between the subclavian artery and descending aorta. The ligamentum arteriosum, which is almost always left sided, is ligated and divided as well.
Dissection should be carried down to the trachea and esophagus to ensure that no constricting fibrous bands remain.
If necessary to minimize residual posterior compression of the trachea/esophagus, arteriopexy may be performed by suturing the retroesophageal aortic segment to the prevertebral fascia.
Video-assisted thoracoscopic division of vascular rings is performed at several centers and appears to be an effective approach in most cases, but data on outcomes are limited. Robotically assisted division of vascular rings has also been reported.
When associated intracardiac anomalies require surgery through a median sternotomy, division of the double arch is performed during the same procedure.
In the current era, essentially no operative mortality is associated with repair of isolated double aortic arch. Outcomes in patients with associated anomalies depend on the coexisting condition.
Postoperative care and precautions
Postoperative care after division of double aortic arch is similar to that for patients undergoing other cardiovascular procedures through a thoracotomy. Most patients experience immediate relief after surgery, although persistent respiratory symptoms and signs may be present, especially in very young infants with severe preoperative symptoms. Except in patients undergoing concurrent repair of associated anomalies, cardiopulmonary bypass is not used during the repair; therefore, postoperative cardiac function typically is not a problem.
Early postoperative complications
Complications in the early postoperative period are uncommon after division of a vascular ring.
The major issue is persistent respiratory symptoms, especially in neonates who are more susceptible to tracheomalacia.
Other rare operative complications include chylothorax resulting from injury to the thoracic duct, diaphragmatic paresis/paralysis secondary to phrenic nerve injury, and, following repair through a left thoracotomy (ie, in patients with a right-dominant double arch), vocal cord paresis/paralysis resulting from injury to the recurrent laryngeal nerve.
No special dietary considerations are indicated in patients with double aortic arch other than those dictated by associated conditions. Postoperatively, enteral feeding is resumed as soon as possible.
In patients with dysphagia or emesis as a presenting symptom, adequate oral intake should be verified, and feeding therapy should be instituted if necessary. In patients with band 22q11 deletion, velopharyngeal insufficiency or cleft palate frequently is present; oral feedings should be resumed with the aid of feeding specialists.
Patients with double aortic arch are not subject to specific restrictions on activity. Prior to repair, activity may be limited by symptoms.
Following repair, any persistent respiratory symptoms resulting from tracheomalacia should dictate activity limitations.
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