IPEG 2020 TOP ABSTRACT: Thoracoscopic Division of a Double Aortic Arch Vascular Ring Anomaly

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.