Complete vascular ring detected by barium esophagography. (Original Article).

Abstract

The diagnosis of a vascular ring can be made on the basis of characteristic findings on barium esophagography. We report a case of a double aortic arch in a 9-month-old girl that was diagnosed in this manner, and we briefly review the anatomic characteristics of vascular rings.

Introduction

Vascular rings can cause airway compression in children. Although the diagnosis is usually confirmed by magnetic resonance imaging (MRI), an initial diagnosis can be made by barium esophagography in most cases. In this article, we describe the case of an infant who was diagnosed in such a manner.

Case report

A 9-month-old girl was brought to us for evaluation of a right-sided aortic arch and associated tracheal narrowing that was detected on chest x-ray. We ordered barium esophagography, which showed a posterior indentation of the midesophagus by an abnormal vessel (figure 1). An anteroposterior image showed a right-sided impression from a right-sided aortic arch and a smaller indentation slightly lower on the left side (figure 2). This was attributed to either a left-sided aortic arch or a large diverticulum of Kommerell. This diverticulum is in fact a dilation of the origin of the aberrant left subclavian artery. Both types of vascular ring--the double aortic arch and the right aortic arch with an aberrant left subclavian artery--can have the same appearance on chest x-ray and barium esophagography. We determined that the vascular ring in this patient was caused by a double aortic arch.

Discussion

The two most common aortic arch anomalies that cause airway compression are (1) a double aortic arch and (2) a right aortic arch with an aberrant left subclavian artery and left ligamentum arteriosum. An aberrant right pulmonary artery (pulmonary sling) and innominate artery compression can also cause airway narrowing. (1) On barium esophagography, an anterior indentation of the esophagus can be seen with pulmonary slings; conversely, the anomalous innominate artery does not produce any changes on barium esophagography.

Abnormal vessels can cause obstruction by either encircling the trachea and esophagus (complete vascular ring) or compressing the anterior wall of the trachea alone. The amount of tracheal and esophageal compression determines the degree of symptoms, which can include dyspnea, stridor, recurrent pulmonary infection, dysphagia, and failure to thrive.

MRI is particularly useful in diagnosing specific tracheobronchial abnormalities, and it is now preferred to the more invasive angiocardiography. (2) Spiral computed tomography and three-dimensional image reconstruction are other noninvasive techniques used in the diagnosis and evaluation of vascular rings. (3) However, barium esophagography is the least expensive of these modalities, and it is an effective and reliable method of investigating and diagnosing suspected vascular rings. (4)

References

(1.) Backer CL, Mavroudis C. Congenital Heart Surgery Nomenclature and Database Project: Vascular rings, tracheal stenosis, pectus excavatum. Ann Thorac Surg 2000;69(4 Suppl):S308-18.

(2.) Simoneaux SF, Bank ER, Webber JB, Parks WJ. MR imaging of the pediatric airway. Radiographics 1995;15:287-98; discussion 298-9.

(3.) Katz M, Konen E, Rozenman J, et al. Spiral CT and 3D image reconstruction of vascular rings and associated tracheobronchial anomalies. J Comput Assist Tomogr 1995;19:564-8.

(4.) Ledwith MV, Duff DF. A review of vascular rings 1980-1992. Ir Med J l994;87:178-9.

From the Department of Paediatric Otolaryngology (Dr. Skinner and Dr. Russell) and the Department of Radiology (Dr. Ryan), Children's Hospital, Dublin.

Reprint requests: Liam J. Skinner, Rossbeigh, Glenbeigh, Co. Kerry, Ireland. Phone: [phone]; fax: [phone]; e-mail: [e-mail]