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IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly
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IPEG 2020 Annual Meeting - Top Abstract
Claire Gerall, MD1; Jennifer DeFazio, MD1; Vincent Duron, MD1; Steven Rothenberg, MD2; 1Morgan Stanley Children's Hospital/Columbia University Irving Medical Center; 2Rocky Mountain Hospital for Children
This video demonstrates that division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5mm stapler. Our patient is a 43-day old male with a vascular ring comprised of a right side dominant double aortic arch. A 4mm camera port was placed in the 5th intercostal space posterior to the tip of the scapula and two 3mm working ports placed in the 7th intercostal space in the posterior axillary line and 3rd intercostal space inferior to the axilla. The left sided ductus arteriosus and recurrent laryngeal nerve were identified. The ductus arteriosus was clamped with stability of vitals prior to transection. The left aortic arch was dissected and the atretic segment clamped without change in vitals. The posterior port was upsized and the left aortic arch was transected using a 5mm stapler, releasing the vascular ring without any complications.
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This video documents a successful fluicroscopic division of a vascular ring anomaly involving a double aortic arch and using a 5 millimeter stapler. The patient is a 43-day-old male x 36 week gestation born with multiple congenital anomalies consistent with Vacterol. On echocardiogram, he was noted to have a vascular ring comprised of a right side dominant double aortic arch with left carotid and subclavian arteries arising from the right arch, as well as an atretic left proximal arch between the origin of the left subclavian artery and left sided patent ductus arteriosis as seen on this image. Prior to the start of the procedure, a right dorsalis pedis arterial line was obtained. A blood pressure cuff was placed on the right arm, and pulse oximeters were placed on the upper and lower extremities. A bronchial blocker was placed in the left main bronchus for single lung ventilation, and patient was placed in right lateral decubous position. Three ports were used a 4 millimeter camera port in the fifth intercostal space just posterior to the tip of the scapula. And 23 millimeter working ports placed in the seventh intercostal space in the posterior axillary line as well as the third intercostal space just inferior to the axilla. A pleural flap was elevated over the descending thoracic aorta and extended superiorly to the thoracic inlet, as well as along the left subclavian artery. Both the left ductus arteriosis as well as the left recurrent laryngeal nerve were identified. A test clamp on the ductus arteriosis was performed to ensure stability of vitals prior to sealing and transecting the ductus. Next, the left aortic arch was bluntly dissected and encircled. The aretic segment at the level of the takeoff of the left subclavian artery was visualized. A test clamp was performed on the atretic segment of the left aortic arch with unchanged blood pressures and saturations. The posterior port was then upsized to a 5 millimeter trocar. The left aortic arch was transected using a 5 millimeter stapler, releasing the vascular ring. This video demonstrates that division of a vascular ring involving large caliber vessels can safely and effectively be accomplished with thoracoscopy and division using a 5 millimeter stapler. There were no intraoperative complications. Our patient returned to the NICU, intubated and was extubated on post-op day one.