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Background Limited data exist on the management of complete vascular rings (CVR) in adults. We reviewed our institution's surgical experience in the management of these patients. Methods Between 2010 and 2019, all adult patients that underwent a thoracotomy for a CVR repair were identified. We performed a retrospective medical record review of these patients to characterize their demographics and outcomes. Results Among the 5 patients identified (3 females, 2 males; Mean age 50 ± 9 years), anatomic variants were right arch and Kommerell diverticulum (KD) in 3 (60%) and double aortic arch in 2 (40%) patients. Indications for operation included dysphagia in 4 (80%), respiratory symptoms in 3 (60%) and aneurysmal KD in 1 (20%) patient. Two right aortic arch exclusion, 1 ligamentum arteriosum (LA) division, 1 LA division combined with a KD resection and 2 aortic reconstructions with interposition Dacron graft under partial cardiopulmonary bypass, were performed. Two carotid-subclavian artery transpositions prior to the thoracotomy were done. The postoperative length of stay was 10.0 (IQR 7.3–14.8) days. One reoperation for chylothorax and 1 for symptoms recurrence were performed for the same patient. Over a follow-up period of 1.4 (IQR 0.4–7.0) years, no mortality or major postoperative complications occurred. At their last follow-up visit, all patients reported no related remaining symptoms, except for persisting mild asthma in 1 patient. Conclusions Open repair of CVR in adults can be performed safely with low complication rate. Symptoms improved in all patients after definitive repair.

OBJECTIVES Vascular rings are rare anomalies of congenital heart disease that cause respiratory and gastrointestinal symptoms. This study assessed the long-term outcomes of patients with vascular ring division. METHODS A multi-institution retrospective review of 371 patients with vascular rings undergoing surgical division at 3 paediatric cardiac institutions between November 2007 and October 2019 was performed. RESULTS The complete vascular rings consisted of a double aortic arch (24.5%), right aortic arch with left ligamentum arteriosum (36.7%) and left aortic arch, with right ligamentum arteriosum (0.5%). The incomplete vascular rings consisted of a pulmonary artery sling (22.9%), left aortic arch with aberrant right subclavian artery (15.1%) and innominate artery compression syndrome (0.3%). Respiratory symptoms included stridor (71.4%), wheezing (49.1%), coughing (31.5%), gastrointestinal symptoms included choking (12.4%), dysphagia (3.2%) and emesis (1.9%). Only one patient died after discharge, yielding a late mortality rate of 0.3% (1/360). The 10-year overall survival rate was 96.8%. Postoperative complications were reported in 51 patients, 15 of whom required reoperation. The 10-year freedom from reoperation rate was 95.9%. Follow-up was completed in 95.4% (354/371) of patients, with a mean follow-up time of 4.3 ± 2.9 years (range from 1 to 13 years). Twenty patients (5.6%) experienced residual symptoms during long-term follow-up. CONCLUSIONS The outcomes of vascular ring division are excellent. A Kommerell diverticulum >1.5 times the aberrant left subclavian artery origin is an operative indication for primary resection. Tracheomalacia is a risk factor for reoperation and residual symptoms, and preoperative fibrobronchoscopy is important for evaluation.

Objective To describe the treatment of persistent right aortic arch (PRAA) in dogs with combined ligamentum arteriosum (LA) transection and esophageal diverticulum resection. Animals Three client owned dogs. Study design Short case series. Methods Medical records were reviewed for clinical signs, diagnostic procedures, surgical treatment, post-operative therapies including medications and feeding regime, outcomes, and follow-up imaging. Results Esophageal resection was performed using a thoracoabdominal (TA) stapler with suture overlay. All dogs recovered well from surgery and did not experience any peri- or post-operative complications. The last follow-up was performed between 64 and 1004 days post-operatively. In all cases, regurgitation resolved and did not recur in any dogs. No dogs required medical therapy or dietary modifications. In two cases, follow-up imaging was performed that revealed marked improvement of esophageal dilation. Conclusion Resection of esophageal diverticulum secondary to PRAA utilizing a TA stapler with suture overlay was technically feasible and did not seem associated with early or late complications.

Neuhauser syndrome is a rare vascular anomaly characterized by the esophagus and trachea circling via the ligamentum arteriosum and right aortic arch. Kommerell’s diverticulum have the same characteristic by an outpouch at the onset of an aberrant left subclavian artery worsening this compression. The association between these pathologies is very rare and the operative strategy is unclear. We describe a case with the association with a computed tomography scanner aortic reconstruction and a repair’s operative strategy.

The gross morphology of the heart of mature Philippine water buffalo was described by determining the weight, length, width and circumference; measured the average external circumference of the pulmonary veins and artery, cranial and caudal vena cava and the aorta; determined the presence and location of ligamentum arteriosum; measured the thickness of the atrial and ventricular wall; described the components of the left and right atrioventricular valves, pulmonary valves and the aortic valves; determined the location and measured the length of trabeculae septomarginalis and determined the location of the os cordis. Hearts of ten mature Philippine water buffalo of both sexes were collected from abattoirs of Cabanatuan City. The absolute and relative weights of the heart were measured using digital weighing scale. Different dimensions like circumferences, length, and width of the heart; the external circumferences of major blood vessels; and the thickness of the wall of heart were determined using measuring tape and Vernier caliper. The number of cusps present in the left and right atrioventricular, pulmonary, and aortic valves was counted and the presence of ligamentum arteriosum was documented. Radiograph was used to determine the presence and location of os cordis. All of the hearts studied were pointed and bilaterally flattened. The base of the heart is markedly surrounded with fatty tissues. The mean absolute weight is 2.42 kg. The heart has a mean dimension of 21.71 cm x 17.49 cm. The mean circumference at the level of the coronary groove, middle and apex were 48.41 cm, 44.10 cm and 20.57 cm, respectively. An average of four pulmonary veins was documented to be present. The right ventricle has a constant three papillary muscles and three cusps while the left ventricle has a constant two papillary muscles and two cusps. The number of cusps of both pulmonary valve and aortic valve was three. Ligamentum arteriosum was present in all samples and it is located between the pulmonary trunk and aorta. The os cordis which is located at the aortic fibrous ring is present in all heart of Philippine water buffalo examined.

Vascular rings (VRs) are rare aortic arch anomalies that may present with a wide variety of symptoms related to esophageal and/or airway compression. We reviewed our surgical experience in both symptomatic and asymptomatic children. All children (n = 58) who underwent surgical repair of VRs or slings (mean age 27.4 ± 45.60 months; 36 males [62%]) between March 2000 and April 2020 were included. The most common anatomic variant was a right aortic arch (RAA) with aberrant left subclavian artery (ALSCA) (n = 29; 50%). Kommerell's diverticulum was present in 23 of these patients (79%). The second most common variant was a double aortic arch (n = 22; 38%), followed by pulmonary artery sling (n = 4; 6%), RAA with mirror image branching and left ligamentum arteriosum (n = 3; 5.2%), and left aortic arch (LAA) with aberrant right subclavian artery (n = 1; 1.7%). One patient had a double ring with pulmonary artery sling and RAA with ALSCA. Symptoms were present in 42 patients (72%). Left lateral thoracotomy was the approach in 50 patients (86%), while sternotomy was used in 8 (14%). Symptomatic improvement occurred in the majority of symptomatic patients (93%). There was one perioperative mortality (1.7%) in the symptomatic group which was non-VR related. Morbidities included recurrent laryngeal nerve injury in three patients (5.2%) and transient chylothorax in two (3.4%). Persistence/recurrence of symptoms resulted in one early and one late reoperation. The mean follow-up was 3 ± 5 years. In the current era, VR repair in children including asymptomatic ones can be performed with excellent results. We recommend complete repair of RAA with aberrant LSCA by resection of Kommerell's diverticulum and translocation of the ALSCA to avoid recurrence.

Circumflex aorta is a rare variant of vascular rings that consists of a right sided aortic arch, posterior crossing aorta from right to left and a left ligamentum arteriosum. While division of the ligamentum may cause partial relief of the aerodigestive tract compression, the ultimate cure for this type of vascular ring is translocation of the posterior crossing aorta anteriorly via what is known as “aortic uncrossing” procedure.

Ligamentum arteriosum calcification may be a normal finding in some children, although the frequency has not been well described. To estimate the frequency of ligamentum arteriosum calcification in children at postmortem imaging. We conducted a single-centre retrospective review of paediatric postmortem CT and chest radiographic imaging over a 6-year period (January 2012 to December 2018). Two independent reviewers assessed the presence of calcification on imaging. We calculated descriptive statistical analysis of ligamentum arteriosum calcification frequency and association with age and gender. During the study period, 220 children underwent whole-body postmortem CT and 182 underwent radiographic imaging. The frequency was higher on postmortem CT than plain radiographs (67/220, 30.5% vs. 3/182, 1.6%) and was highest in children ages 1–7 years (53.6–66.7%), with gradual reduction in frequency in older children, and none in children older than 12 years. There was no gender predilection. In the postmortem setting, ligamentum arteriosum calcification is a common finding in children

A previously healthy, one-year-old, intact female Vizsla dog collapsed and experienced cardiopulmonary arrest after a stressful event. Postmortem examination identified juxtaductal aortic coarctation (AoCo) with complex morphology. Located in the isthmus aorta adjacent to the ligamentum arteriosum, the AoCo comprised a shelf-like structure caused by invagination of the aortic wall into the lumen. Just distally, a second region of aortic occlusion resulted from an obstructing aortic membrane that restricted blood flow into the descending aorta through a small, eccentric ostium. Plausibly, the AoCo contributed to high afterload which led to reduction of coronary blood flow, myocardial hypoxia, and sudden death during physical stress. Although AoCo is a well-recognized congenital defect in humans, it has been reported only rarely in animals. The present case details the gross and histologic features of a complex, juxtaductal AoCo in a dog who died suddenly after stress. These morphologic findings may be informative when contemplating diagnosis of this anomaly.

This report documents the first case of gossypiboma (textiloma) identified within the thorax of a dog. CT findings, surgical removal and histopathology are described. Intra-thoracic gossypiboma has not previously been reported in dogs and is rarely reported in the human medical literature, where it is most commonly associated with previous cardiac or pulmonary surgery. This dog had previously had a thoracotomy for attempted surgical correction of a persistent right aortic arch and left ligamentum arteriosum 6 years prior to presentation. A brief review of the previous literature and recommendations for prevention of this condition are provided.

OBJECTIVES Recurrent laryngeal nerve (RLN) injury during thoracic surgery may result in life-threatening postoperative complications including recurrent aspiration and pneumonia. Anatomical details of the intrathoracic course are scarce. However, only an in-depth understanding of the anatomy will help reduce nerve injury. The aim of this study was to assess the anatomic variations of the intrathoracic left RLN. METHODS Left-sided vagal nerves and RLN were dissected in 100 consecutive Caucasian cadavers during routine autopsy. Anatomical details were documented. Available demographic data were assessed for possible correlations. RESULTS All nerves were identified during dissection. Variant courses were classified in 3 different groups according to the level at which the RLN separated from the vagal nerve: above the aortic arch, level with the aortic arch and below the aortic arch. We found 11% of RLN separating above the aortic arch and crossing the aortic arch at a considerable distance to the vagal nerve. In 48% of the RLN, the nerve split off when it was level with the aortic arch, and 41% of the RLN leave the vagal nerve in a perpendicular direction below the aortic arch. All nerves crossed the ligamentum arteriosum on the posterior side. No gender-specific differences were observed. CONCLUSIONS Mediastinal lymph node dissection in left-sided lung cancer patients puts the RLN at risk. With more detailed anatomical knowledge about its course, it is possible to avoid risking the nerve. Visualization will help protect the nerve., Left recurrent laryngeal nerve (L-RLN) palsy is a severe complication following various thoracic surgical procedures.

Background This single-institution study assessed the midterm outcomes of patients undergoing complete vascular ring (CVR) repair and the need for reintervention. Methods The study included all patients who underwent surgical repair of an isolated CVR from 1996 to 2018 at our institution. Patients who underwent concomitant intracardiac repair were excluded. Data analysis included demographics, type of anomaly, other congenital heart disease, clinical symptomatology, operative technique, perioperative outcomes, reoperation rates, and mortality. Results CVR repair through open thoracotomy was performed in 148 patients (80 boys [54%]), median age, 1.04 years (interquartile range, 0.4-5.2 years), and median weight, 12.8 kg (interquartile range, 7.5-26.5 kg). The cohort included 72 patients with double aortic arch (DAA), 69 with right aortic arch (RAA) with aberrant left subclavian artery and left ligamentum arteriosum (LLA), 5 with RAA with left descending aorta and LLA, and 2 with RAA with mirror-image branching and LLA. There was 1 outpatient perioperative death (0.7%) 15 days postoperatively. Perioperative complications occurred in 20 patients (14%): 18 (12%) with chylothorax (3 required reintervention), 1 pneumothorax, and 1 vocal cord paresis. Two of 36 patients (5.5%) without primary diverticulum resection required reoperation and subclavian reimplantation at 3 and 4 years, and 1 patient required aortic translocation 9 years later for persistent symptoms. Conclusions Freedom from reoperation after CVR repair was 93% at 5 years and 86% at 10 years. A small proportion of patients who do not undergo diverticulum resection and aberrant left subclavian artery reimplantation at the time of CVR repair will require reintervention in the future.

We present a case of an 87-year-old female with new-onset hoarseness of unclear etiology. Imaging demonstrated a penetrating aortic ulcer (PAU) in the proximal descending thoracic aorta with an associated pseudoaneurysm that enlarged to a depth of 32 mm over 2 years. This patient was diagnosed with hoarseness being secondary to left recurrent laryngeal nerve (LRLN) palsy, a variant of Ortner syndrome. Patient was treated with endovascular stent-grafting successfully covering of the PAU and pseudoaneurysm with zone 3 proximal landing zone. The patient had moderate improvement in hoarseness after 1 year of follow-up. Endovascular repair is indicated for symptomatic patients with PAUs complicated by enlarging pseudoaneurysms or rupture. Endovascular treatment is effective with low procedural morbidity and mortality. In this case, the PAU and associated pseudoaneurysm at the level of the ligamentum arteriosum caused compression on the LRLN, resulting in a nerve palsy and hoarseness. This case highlights the importance of vascular imaging for patients presenting with unclear etiology of hoarseness or other signs of LRLN palsy. Therefore, aortic arch abnormalities, a variant of Ortner syndrome, even though rare, should be on the differential diagnosis of new onset hoarseness.

Objective This study highlights the management strategy in simultaneous bicuspid aortic valve infective endocarditis and mycotic pseudoaneurysm of an aortic coarctation. Methods A staged repair of mycotic pseudoaneurysm of aortic coarctation and infective bicuspid aortic valve endocarditis. Results We present a 19-year old gentleman who was admitted with aching pain in his bilateral lower extremities with associated purpuric rash and fevers. Work-up was significant for severe aortic valve regurgitation and a pseudoaneurysm in the distal aortic arch. He underwent operative repair through a left posterior-lateral thoracotomy with femoral-femoral partial cardiopulmonary bypass. Intraoperative findings were significant for a juxta-ductal coarctation and pseudoaneurysm. The mycotic pseudoaneurysm and remnant ligamentum arteriosum were completely resected and were replaced with a 18 mm Gelweave graft (Terumo Cardiovascular Group, Ann Arbor, MI) from the distal arch to the descending thoracic aorta. The patient underwent a planned secondary washout and omental flap for biologic coverage of the graft. Subsequently, a staged aortic valve replacement was completed 1 week later. The patient's postoperative course was uncomplicated, and he was discharged with intact motor and sensory function. Conclusions A staged approach is a prudent strategy to manage a patient with simultaneous endocarditis and aortic mycotic pseudoaneurysm, with precedence toward the most critical lesion.

Introduction: The recurrent laryngeal nerve gains its name because after branching from the vagus nerve, it turns superiorly (recur) around the subclavian artery on the right and around the ligamentum arteriosum on the left, the nonrecurrent nerve has a straight direct course to the larynx and doesn’t follow this course. It presents mostly on the right side. The presence of this variation places the nerve at higher risk of injury during neck surgery especially thyroid operations. Case Presentation: A 45-year-old lady presented with painless thyroid enlargement for 1 year. Thyroid examination showed a 3-cm firm nodule at the right thyroid lobe with normal thyroid function tests. Right thyroid lobectomy was done and the histopathology showed a benign follicular lesion. During surgery, we discovered 2 nonrecurrent laryngeal nerves at the right side which were arising from the vagus nerve and both were entering the larynx. Conclusion: Failure in identification of the nerve or overlooking the possibility of the non-recurrent laryngeal nerve may result in a serious sequelae of nerve damage, ipsilateral injury may lead to permanent hoarseness and bilateral injury may result in severe dyspnea or aphonia. Currently, there are 3 types of nonrecurrent laryngeal nerve courses. Type 1 passes near to the superior thyroid vessels. Type 2 (2A) passes parallel to the inferior thyroid artery and has a transverse course above it. Type 3 (2B) passes parallel to the inferior thyroid artery and transversely between branches of or under the inferior thyroid artery, we can add to this classification type 4, which are 2 nonrecurrent laryngeal nerves (double nerves) passing above and parallel to the inferior thyroid artery.

The right aortic arch with aberrant left subclavian artery is the most common cause of vascular ring and can be either asymptomatic or symptomatic owing to mass effect. Removal of Kommerell diverticulum and division of the ligamentum arteriosum through a left thoracotomy is currently advocated in symptomatic patients and patients with large diverticulum (>5 cm) to avoid inherent complications.

Objective To determine and report the diagnosis, treatment, and outcome in dogs with persistent right aortic arch (PRAA) with an aberrant left subclavian artery (ALS) that underwent thoracoscopic surgery. Animals Dogs with PRAA and an ALS (n = 5). Study design Short case series. Methods Medical records were reviewed from 2014 to 2019. Dogs that underwent thoracoscopy for PRAA with an ALS at an academic referral hospital were included. Signalment, clinical signs, diagnostic imaging, surgical approach, complications, and short- and long-term outcomes were recorded. Results Persistent right aortic arch with an ALS was identified in five dogs. Dogs initially underwent a three-port intercostal thoracoscopic approach, and an intercostal thoracotomy was performed in converted cases. In all five dogs, the ligamentum arteriosum (LA) and ALS were divided; three were performed by a thoracoscopy alone. Two cases were converted because of poor exposure (1) and requirement to temporary occlude an ALS (1). The ALS was ligated and divided in all dogs without apparent negative effects. No intraoperative or postoperative complications occurred. Four dogs had resolution of regurgitation, three of which required diet modification. One dog had reported regurgitation when it was excited. Median follow-up was 188 days (range, 150-1133). Conclusion Ligation and division of both the LA and the ALS in all dogs in this case series was safe and allowed for improvement in clinical signs and good to excellent long-term outcomes. In addition, both thoracoscopy and thoracotomy were used safely and successfully for ligation and transection of the LA and ALS in all dogs.

Introduction: The ligamentum arteriosum is generally considered a mere remnant of the embryonic bypass (ductus arteriosus) from the pulmonary circulation to the aortic arch, obliterating soon after childbirth. However, there have been anecdotal contradictory reports about this structure. This study set out to elucidate the morphology, innervation and neurochemistry of LA innervation. Method: LA of human, pig, wild-type and transgenic mice were studied using routine and special histological staining methods, single- and double-immunofluorescence labeling using antibodies directed against structural markers, neuropeptides, and transmitter synthesizing enzymes such as α-smooth muscle actin (αSMA), neuropeptide Y (NPY), and tyrosine hydroxylase (TH) respectively. Ultrastructural studies of pig and mice LA using Transmission electron microscopy (TEM) was employed. Pig LA was subjected to varying Hz of electrical field stimulation, increasing cumulative doses of noradrenalin and alpha 1 adrenergic blockers (tamsulosin and prazosin). Results: Contrary to a canonical ligament, the ligamentum arteriosum was mainly made up by αSMA-positive cells in all three species as observed from results of immunofluorescence labelling and histological staining. TEM confirmed the presence of vascular smooth muscle cells within LA tunica media. Additionally, myofilaments, dense bodies and bands, all relevant in the formation of the contractile apparatus of vascular smooth muscles were observed. The LA received a noticeable amount of chrna3-eGFP. PGP 9.5, TH, NPY, SP, CGRP -positive fibers were observed in all three species. TEM revealed nerve terminals in close proximity to smooth muscle cells. The LA had a frequency and dose dependent contraction in response to electrical field stimulation and exogenous noradrenalin respectively. There was also a dose dependent relaxation upon administration of tamsulosin and prazosin . Conclusion: It is fact that the LA no longer serves in its original capacity as a foetal shunt connecting the two great vessels. However, the presence of contractile smooth muscle is present long after obliteration and until senescence. These muscular elements have noticeable sympatheic and sensory innervation. It may be postulated that the contractile abilities of LA myocytes may act on the two great vessels to which it is attached causing a change in their distensibility.

Aortic coarctation is a congenital narrowing and stenosis in the aorta that is most frequently located near the ligamentum arteriosum and the left subclavian artery. Coarctation in adults is now usually treated with catheter intervention with good follow-up results. However there are coarctation types that are anatomically challenging for catheter intervention. Here we present a patient with an angulated aortic arch who underwent successful coarctoplasty and stenting.

We report a case of chylous leak recognized post-operatively after abdominal surgery for left para-aortic paraganglioma in a young female with a history of open botallo’s duct. Conservative measures failed to control the leak and the patient is not eligible for sclerotisation. Laparoscopic exploration with intralipidand methylen blue injection through an orogastric tube revealed the leaking area near the superior mesenteric vein behind the Traitz, and this was ligated with non-asorbable suture and placement of acrylic glue. The patient was discharged the 7th post-operative day after removal of the drainage which appeared to supply

Anomalies of the aortic arch associated with Kommerell diverticulum (KD) are rare congenital malformations. Symptomatic thoracic vascular rings presenting in adults are rare. We report a case of a 39‐year‐old woman who was diagnosed with uncontrolled asthma. She was complaining of worsening respiratory symptoms with dysphagia. Imaging studies and preoperative findings concluded to type II congenital anomaly of the aortic arch or Neuhauser's anomaly: a right‐sided aortic arch with aberrant left subclavian artery, tracheoesophageal compression by KD and ligamentum arteriosum (LA). This compression was relieved by the resection of the LA and KD., We report a rare case of vascular ring with Kommerell diverticulum leading to a misdiagnosis of asthma in a 39‐year‐old woman.

We describe an uncommon association of crossed pulmonary arteries and a right aortic arch with a Kommerell diverticulum and a left ligamentum arteriosum, resulting in disabling dysphagia in a 33-year-old woman. First, endovascular exclusion of the Kommerell diverticulum was performed using a thoracic stent graft, associated with left subclavian-carotid transposition. Second, open aneurysmorrhaphy and division of the left ligamentum arteriosum allowed a proper release of the oesophageal compression. Dysphagia completely disappeared in the postoperative course. Control computed tomography angiography at 6-month follow-up showed a satisfactory hybrid repair. A complete understanding of the combined effects of these two anatomical variations on oesophageal compression led to a suitable surgical management.

In mammals, the recurrent laryngeal nerve (RLN) loops around the ligamentum arteriosum on the left side and around the subclavian artery on the right side. It is generally considered that such an asymmetric arrangement of the right and left RLN is brought about by a transformation of the aortic arches at an early stage of embryonic development. We have dissected rough-toothed dolphins and Pacific white-sided dolphins in this study. In both species, the right RLN hooked around the costocervical trunk, while the left RLN hooked around the ligamentum arteriosum. The external carotid artery, the internal carotid artery, the subclavian artery, and the costocervical trunk arose radially from the brachiocephalic trunk on the right side. The left costocervical trunk arose directly from the aortic arch. The right and left subclavian arteries ran ventral to the subclavian vein and the vagus nerve, in a similar manner to the secondary subclavian arteries in birds. These findings suggest that the replacement of the primary (or dorsal) subclavian artery by the secondary (or ventral) subclavian artery might occur at a certain embryonic stage in dolphins as well.

Left mediastinal node dissection during lung cancer surgery can be difficult because paratracheal and subcarinal lymph nodes are concealed by mediastinal structures. Arterial ligament transection (ALT) offers a wide surgical view of concealed mediastinal spaces, thus enabling extendedWe retrospectively investigated the medical records of 75 patients who had undergone extended mediastinal node dissection after ALT via VATS for potentially node-positive NSCLC at our centers during the period from September 2008 through November 2015. Operative data and rates of overall survival (OS), in addition to mortality and morbidity, were analyzed in relation pathological stage and nodal stage.Operative time was 238±58 minutes, and an average of 32.7±12.9 hilar and mediastinal lymph nodes were dissected. Lymph node metastases were detected in 34 patients (6 pN1 patients, 27 pN2 patients, and 1 pN3 patient). Mediastinal lymph node metastases were detected around the carina (stations 2L, 4L, and 7) in 19 of 27 patients with pN2 cancer. Nineteen patients had a total of 24 postoperative complications. Recurrent nerve paralysis was the most frequent complication (n=11) but resolved in eight patients during follow-up. Survival rates at 3 and 5 years were 92.2%/88.4%, 100.0%/60.0%, and 87.7%/81.0% for p-stage I, II, and III, respectively, and 92.2%/88.4%, 100.0%/60.0%, and 87.4%/80.7% for pN0, pN1, and pN2, respectively.Extended mediastinal node dissection after ALT allowed detection of lymph node micrometastases in selected patients with potentially node-positive left NSCLC and may improve outcomes.

A right aortic arch vascular ring consists of an anomalous aortic arch course with a ligamentum arteriosum and an aberrant left subclavian artery arising from a Kommerell diverticulum. Division of the ligamentum arteriosum is required for the relief of symptoms in these patients. However, to prevent recurrent symptoms, resection of the Kommerell diverticulum and reimplantation of the subclavian artery to the left carotid artery is advocated. Here we describe our standardized surgical approach to this pathology.

Kommerell diverticulum is a rare developmental anomaly of aortic arch. It is most frequently seen with right-sided aortic arch and aberrant left subclavian artery or ligamentum arteriosum, which have a significant role in completing a vascular ring. However, aberrant origin of neck vessels along with it is not commonly seen. The signs and symptoms vary depending on the severity. The paediatric patients usually present early due to compression of mediastinal structures such as trachea or oesophagus.

BACKGROUND The Gerbode left ventriculo-right atrial defect is a very rare congenital anomaly. Gerbode described two routes for blood to travel from the left ventricle to the right atrium, a direct or supravalvular or (type A) and an indirect (type B) or infravalvular. Case Characteristics- A male born to nonconsanguineous couple and had indirect type C Gerbode VSD. Observation- The child had midmuscular VSD. Blood flow from left ventricle to right ventricle through midmuscular VSD and then through tunnel formed by tricuspid to right atrium. Outcome- Parent advised to go for further investigation. Message-A rare congenital malformation to be suspected when any child with midmuscular VSD have tricuspid regurgitation.

An 18-month-old girl was suspected fish-bone foreign body on computed tomography. She was finally diagnosed to have the calcification of the ligamentum arteriosum. It is important to be aware of the presence of it to avoid further unnecessary examinations.

A 79-year-old man presented with an enlarging thoracic aneurysm on the background of superficial bladder cancer treated with intravesical bacillus Calmette-Guérin (BCG) injections. Following the injections, he developed deranged liver function tests and hepatomegaly. Liver biopsy revealed granulomatous hepatitis compatible with disseminated mycobacterial infection (BCG-osis) and was treated with anti-tuberculosis agents for 12 months. A surveillance CT scan performed as a follow-up for his bladder cancer in 2018 revealed a saccular thoracic aneurysm at the ligamentum arteriosum, which was metabolically active on positron emission tomography (PET) scan. Given the timeframe from intravesical instillation of BCG and the metabolic activity on PET scan, the lesion was consistent with a mycotic aneurysm secondary to disseminated mycobacterial infection. Following multidisciplinary team discussion, a thoracic endovascular aneurysm repair was performed. The stent grafts were placed distal to the left subclavian artery with good angiographic results and no immediate postoperative complications. He was initiated on long-term antibiotics to cover potential bacterial pathogens including mycobacterium.

The left recurrent laryngeal nerve (RLN) is prone to get compressed or damaged, leading to vocal cord palsy, due to pathologies or surgeries of the structures closely surrounding this nerve in the thorax, including the esophagus, aortic arch, pulmonary trunk, and ligamentum arteriosum. We wanted to provide a data set including nerve diameter, its distance from the esophagus, measurements of the pulmonary artery, aorta, and ligamentum arteriosum in close proximity of the nerve in a healthy population to avoid its damage during surgery and predict its chances of compression during the diseased condition. We measured the left RLN and the surrounding structures in 39 well-embalmed cadavers. We compared the values among the male and female cadavers. We found that the mean diameter of the left RLN was 1.75 mm, the mean distance of the nerve from esophagus was 9.88 mm, the mean diameters of the aortic arch and pulmonary artery just distal to the attachment of the ligamentum arteriosum were 26.14 and 19.93 mm, respectively, and the length and width of ligamentum arteriosum were 15.89 and 2.79 mm, respectively. No clinically significant differences were found between male and female parameters. This set of values might be useful while investigating the cause of vocal cord palsies or during surgeries in close proximity to left RLN to avoid its damage.

The thoracic aorta extends proximally from the aortic annulus to the diaphragmatic crura distally. It is subdivided into three parts: the ascending aorta, the arch and the descending aorta. The ascending aorta comprises the aortic root and the tubular ascending aorta. The aortic root lies between the aortic annulus and the sinotubular junction. The sinuses of Valsalva arise from the aortic root. The tubular ascending aorta runs from the sinotubular junction to the brachiocephalic trunk. The coronary arteries are the only branches of the ascending aorta. The aortic arch begins at the brachiocephalic trunk and ends at the origin of the left subclavian artery. The isthmus extends from the left subclavian artery to the ligamentum arteriosum. Three branches usually arise from the aortic arch: the brachiocephalic trunk, the left common carotid artery and the left subclavian artery. The brachiocephalic trunk divides into the right common carotid artery and the right subclavian artery. In 6% of people, the left vertebral artery arises directly from the arch [1]. The bovine arch is another variant in which the left common carotid artery arises from the brachiocephalic trunk rather than the aorta [1]. Another arch variant is the ductus diverticulum, a focal bulge along the inner aspect of the isthmus representing a remnant of the ductus arteriosus. Traumatic aortic transection also occurs in this location and can occasionally be difficult to differentiate from a ductus diverticulum. However, the ductus diverticulum has smooth margins with obtuse angles relative to the adjacent aorta. Aortic transection has irregular margins with acute angles relative to the nearby aortic walls.

The aim of this study was to attempt to carry out the analysis and interpretation of the clinical course of the disease in children with documented congenital heart disease - patent ductus arteriosus. To compare the data with the size of auscultation of patent ductus arteriosus and the direction to be bypassed through the blood stream, obtained during routine echocardiography. Using echocardiography to examine abnormal diastolic flow in the pulmonary artery trunk, simulating patent ductus arteriosus. Echocardiography was performed in 2173 a child under the age of 1 day of life to 18 years. Of these outpatient echocardiographic study was performed in 1503 children permanently surveyed 670 children. Patent ductus arteriosus was diagnosed in 66 children, which made up 3% of the total surveyed. Of these, 48 girls and 18 boys (ratio 2.6 : 1). In the classification of the identified patent ductus arteriosus, we have a new form of it has been identified and proposed - a continuously recurrent, which met in 5 children. When comparing the data auscultation with different kinds of patent ductus arteriosus was found that the classic “machine” systolic-diastolic murmur, accompanied by only 20% of defects, 60% of the children to listen to a systolic murmur in the 2-3 intercostal space on the left in the sternum, in some cases accompanied by focus 2nd tone of the pulmonary artery. The remaining 20% of the children surveyed, a significant auscultatory pattern generally absent. The paper presents the criteria for echocardiographic diagnosis between patent ductus arteriosus, and pulmonary and aorto-coronary-pulmonary fistulas, and fistulas. It is shown that when rendering the bifurcation of the pulmonary artery from the left parasternal short-axis access, deficiency or complete absence of tissue in the projection of aorto-pulmonary ligaments (ligamentum arteriosum), may indicate the presence of a patent ductus arteriosus.

Objective To report the diagnosis, treatment, and short-term outcome in dogs with suspected persistent right aortic arch (PRAA) undergoing thoracoscopy with concurrent esophagoscopy. Study Design Multi-institutional retrospective case series. Animals Dogs with suspected PRAA (n=9). Methods Medical records were reviewed from 2012 to 2016. Dogs undergoing thoracoscopy for PRAA at 3 referral hospitals were included. Signalment, clinical signs, diagnostic imaging, anesthesia protocol (including the use of one-lung ventilation), surgical approach, complications, and short-term outcome were recorded. Dogs underwent a left-sided intercostal thoracoscopic approach with concurrent intraoperative esophagoscopy. The ligamentum arteriosum (LA) and constricting fibers were divided using a vessel-sealing device using a 3 or 4 port thoracoscopy technique. Visualization and dissection of the LA was aided by transesophageal illumination by esophagoscopy. Results Thoracoscopy confirmed PRAA in 9 dogs, with an aberrant left subclavian artery (LS) identified in 5 dogs. Major complications occurred in 2 dogs: postoperative hemorrhage from the LS and esophageal perforation, which resulted in euthanasia. Median follow-up was 250 days (range, 56–1,595). Regurgitation resolved in 4 of 8 surviving dogs. One dog had recurrence of regurgitation 1,450 days postoperatively, esophageal compression by the LS was identified, and regurgitation resolved following LS transection. Conclusion Esophagoscopy aided identification and dissection of the LA in all cases. Due to the potential for the LS to cause clinical esophageal constriction postoperatively, a recommendation for LS transection may be warranted. Vascular clips can also be considered as an alternative for vessel ligation to avoid complications associated with vessel-sealing device use.

We describe a rare case of the right-sided aortic arch, the unusual origin of the main arterial vessels and the unusual courses of bilateral recurrent laryngeal nerves in a Japanese cadaver. Chiefly, the right-sided aortic arch turned to the left side from the dorsal part of the trachea and esophagus, and Kommerell's diverticulum was found at the end of the arch. The right common carotid artery arose from the end part of the ascending aorta, but the left common carotid artery arose from the proximal portion of the ascending aorta. The right subclavian artery arose from the upper edge of the aortic arch, but the left one arose from the front wall at the upper side of the ligamentum arteriosum. The right recurrent laryngeal nerve hooked around the aortic arch (but not the right subclavian artery) dorsoventrally, and the left recurrent laryngeal nerve hooked around the ligamentum arteriosum and arose from the ventral side (but not dorsal) of the aortic arch. These variations are very rare, and understanding them is useful and important for clinical research.

An entity that has received little attention as cause or recurrent respiratory disorder is the narrowing of the left main stem bronchus. When not associated with congenital heart disorders, this condition has been ascribed to primary localized malacia of the bronchial cartilages or to the anterior displacement of the descending aorta in front to the adjacent vertebral bodies. Four girls were evaluated for recurrent/chronic respiratory symptoms. A pulsatile extrinsic compression on the posterior bronchial wall of the left main stem bronchus was detected, pressed between the descending aorta, posteriorly, and the left pulmonary artery, anteriorly. The two arteries were closely linked together by a short-length ligamentum that was resected, allowing the mobilization of the aorta with posterior aortopexy, stabilizing the space created between the pulmonary artery and the descending aorta. The reduced compression on the left main bronchus resulted in the enlargement of its caliber and in a marked improvement of the respiratory symptoms. Pediatr Pulmonol. 2016;51:1356-1361. © 2016 Wiley Periodicals, Inc.

Vascular rings occur due to some perturbation in the normal sequence of development and selective involution of paired aortic arches to form a definitive left or right aortic arch. The two most common types of vascular rings are double aortic arch (DAA) and right aortic arch with an aberrant left subclavian artery and a left patent ductus arteriosus or ligamentum arteriosum (RAA-ALS) (1,2). The prevalence of vascular rings is unknown because many patients remain asymptomatic and are undiagnosed.