Reducing the Trauma of Reducing the Trauma of Vascular Ring DivisionVascular Ring Division

Redmond P. Burke, M.D.Redmond P. Burke, M.D.Chief, Division of Cardiovascular Chief, Division of Cardiovascular SurgerySurgeryThe Congenital Heart InstituteThe Congenital Heart InstituteMiami Children’s HospitalMiami Children’s Hospital20112011

Surgical History of Vascular Surgical History of Vascular RingRing

Fig. 4. Pitx2c in remodeling the great vessels and outflow tract. (A) Remodeling of aortic arch arteries and derivation of mature aortic arch vessels (adapted from Moore, 1982). Cathy WaltersE-mail: cathy@biologists.com

First surgical division by Dr Robert GrossAt Boston Children’s Hospital in 1945

First Video-assisted thoracoscopic vascular ring division by Burke at Boston Children’s Hospital in 1993, 48 years later

Clinical Presentation may be variable: Clinical Presentation may be variable: breathing problems, swallowing breathing problems, swallowing

problems, both, or nothing.problems, both, or nothing.

This child was diagnosed when he swallowed a coin.

Barium SwallowBarium Swallow

Remains the “Gold Standard” for diagnostic tests.

Surgical Approach: Thoracotomy vs Surgical Approach: Thoracotomy vs Video Assisted Thoracoscopic Surgery Video Assisted Thoracoscopic Surgery

(VATS)(VATS)

Our SurgicalOur Surgical Approach: Approach:

Reduce Reduce cumulative cumulative

patient trauma patient trauma with a video with a video

assisted assisted thoracoscopic thoracoscopic approach to approach to avoid a large avoid a large chest incisionchest incision

How we Definine The Perfect How we Definine The Perfect Approach for Vascular Ring Approach for Vascular Ring

DivisionDivision No breast traumaNo breast trauma No muscle traumaNo muscle trauma No nerve traumaNo nerve trauma Put the surgeon close to the lesion, Put the surgeon close to the lesion,

allowing precise diagnosis, allowing precise diagnosis, dissection, suturing, and vascular dissection, suturing, and vascular controlcontrol

Double Aortic Arch Double Aortic Arch DissectionDissection

Completed DivisionCompleted Division

Surgical note:

We precisely cut the scar tissue on the surface of the esophagus

Video of Vascular ring division:Video of Vascular ring division:Right Aortic Arch, aberrant left Right Aortic Arch, aberrant left

subclavian, left ligamentumsubclavian, left ligamentum

Surgical Techniques for Ring Surgical Techniques for Ring Sling ComplexSling Complex

Surgical philosophy:

Repair the trachea and the left pulmonary artery in the least traumatic way. Follow the LPA closely.

Innominate Suspension: for Innominate Suspension: for patients with innominate artery patients with innominate artery

compression of the tracheacompression of the trachea

Surgical Options:

Anterior tacking of the innominate artery to the sternum, or detachment and reimplantation of innominate artery

Potential Surgical Potential Surgical Complications after vascular Complications after vascular

ring divisionring division Recurrent or Phrenic Nerve injuryRecurrent or Phrenic Nerve injury Persistent vascular ringPersistent vascular ring

Caused by the surgeon missing one element of a double Caused by the surgeon missing one element of a double aortic archaortic arch

Chylothorax: Chylothorax: Caused by damage to the Thoracic duct.Caused by damage to the Thoracic duct.

HemorrhageHemorrhage Caused by injury to the aortic arch vessels.Caused by injury to the aortic arch vessels.

Persistent SymptomsPersistent Symptoms It is fairly common for patients to have long term reactive It is fairly common for patients to have long term reactive

airways (like asthma) even after ring division.airways (like asthma) even after ring division. We think this might justify earlier intervention on We think this might justify earlier intervention on

asymptomatic patients, to avoid this long term injury to asymptomatic patients, to avoid this long term injury to the airway.the airway.

Surgical OutcomesSurgical Outcomes

Miami Children’s ExperienceMiami Children’s Experience N= 24, DAA 14, RAA/ALSCA 8, PA sling 2N= 24, DAA 14, RAA/ALSCA 8, PA sling 2 Age Median 2 months, range 8 days to 42 yearsAge Median 2 months, range 8 days to 42 years Weight Median 6.4 kg, range 2.5 kg to 78 kgWeight Median 6.4 kg, range 2.5 kg to 78 kg Hospital Stay Median 5 days, range 1 to 27 daysHospital Stay Median 5 days, range 1 to 27 days Mortality: zeroMortality: zero MorbidityMorbidity

Major: noneMajor: none Minor: Atelectasis 3/24Minor: Atelectasis 3/24

Thank YouThank You