Pulmonary artery sling: diagnosis and surgical treatment

Abstract

The aim — to study the experience in surgical treatment of isolated and associated pulmonary artery sling including tracheal, cardiac and aortic arch anomalies, to analyze the treatment strategy, complications and their correction. Materials and methods. Esophagography, digital subtraction angiography, contrast chest CT, tracheobronchoscopy, echocardiography were used for diagnosis. Surgery was used in all cases despite patient’s age, severity and associated lesions. Results and discussion. Over the 35-year period (1982 — 2017), 93 children were diagnosed and operated with different types of vascular rings in one center. Most of patients were under 3 year of age (n = 75; 80.6 %). Total of 8 (8.6 %) patients having pulmonary artery sling were included to the study. One of them had double vascular ring which included pulmonary artery sling and double aortic arch. Patients’ age at operation ranged from 21 days to 24 months (mean 12.9 ± 2.3, median 12.5), and weight ranged from 3.7 kg to 12.5 kg (mean 9.6 ± 0.9 kg, median 9.3 kg). Four of them (group I) (50 %) had isolated pulmonary artery sling and other 4 had associated airway or cardiac malformations (group II). Associated anomalies were as following: complete rings tracheal stenosis (n = 4), ventricular septal defect (n = 1), double vascular ring and total anomalous venous drainage (n = 1). Isolated pulmonary artery sling was corrected through left thoracotomy without cardiopulmonary bypass. Vascular anastomosis was performed using «fish mouth» technique to prevent postoperative stenosis. Median sternotomy and bypass were used in case of associated tracheal stenosis and ventricular septal defect. Tracheal resection or slide tracheoplasty were used for tracheal stenosis. In patient with double vascular ring and anomalous venous drainage surgery was staged: Rashkind procedure; then division of double aortic arch and left pulmonary artery reimplantation. Survival rate in the group I was 100 %, whereas in the group II 3 patients died, including that with double vascular ring. Overall mortality was 37.5 %. Stenosis of vascular anastomosis was corrected by balloon dilation in one case. Conclusions. Isolated pulmonary artery sling could be corrected through left thoracotomy without cardiopulmonary bypass, whereas associated anomalies should be managed using sternotomy approach and bypass. «Fish mouth» vascular anastomosis is effective in prevention of its stenosis. Balloon dilation of stenotic anastomosis in late period allows restoring an adequate blood flow in the left lung. Associated tracheal stenosis and cardiac defects has significant influence to the increase of mortality in patients with pulmonary artery sling. In case of associated heart defects simultaneous repair of cardiac hemodynamics and decompression of respiratory tract is expedient