Discussion:
A right aortic arch with a left aberrant subclavian artery, as seen in this patient, is the second most common form of vascular ring anomaly after the double aortic arch1. In our case, the ring was completed by a PDA running between MPA and ASA which is unusual (Figure 2B).
The conventional approach is division of the ligamentum arteriosum or PDA to relieve compression caused by the vascular ring allowing the structures to retract away from the tracheo-oesophageal complex2. This can be also achieved with minimally invasive methods but with a higher chance of recurrence of symptoms requiring re-intervention3. Translocation of the ASA to the carotid artery via lateral thoracotomy has better outcomes than the above approaches2,3 but this technique applies to isolated vascular rings without coexisting intracardiac lesions and our child had large septal defects that also required closure in the same sitting. A single approach to treat vascular rings with intra-cardiac defects that has a lower risk of re-intervention remains undescribed.
In our patient, a lateral thoracotomy approach was not considered in view of co-existing intra-cardiac shunts. A dual incision approach comprising of supraclavicular access and a sternotomy had obvious disadvantages of increase in operative time with attendant morbidities and 2 visible scars. Moreover, complete translocation of the ASA without a CPB from sternotomy was risky as the ASA was posterior to the trachea and oesophagus with chances of injuring the oesophagus during dissection and mobilisation. In view of these, it was thought that a midline approach using CPB was ideal because it gave access to the vascular ring, increased safety and also provided the option of closing the intracardiac defects. Besides, it also provided better access to mobilise the ASA after exit from its tracheo-oesophageal relation.
Conclusion: To conclude, our single-stage and single-incision approach has several additional advantages and early result have been encouraging.
  1. It enabled total correction of vascular ring and also closure of septal defects in a single stage and single incision.
  2. Complete removal of pulsatile blood flow posterior to the trachea and oesophagus without injuring them.
  3. Minimal damage to the second and third part of the subclavian artery which is associated with increased risk of vascular compromises4.
  4. It was quicker, cosmetically superior and less morbid as compared to other approaches5.
  5. It eliminated chances of the recurrence of symptoms due to transection and reimplantation of ASA.