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कपाकीDR. UMESH KHEDKAR
D.M. CARDIOLOGY RESIDENT.
LTMGH , MUMBAI.
 Account for 15% to 20% of all congenital
cardiovascular diseases.
 Result from errors in the embryologic
development of...
 Can be discovered when there are symptoms
of airway or esophageal compression
produced by vascular rings, or anomalies c...
Anomalous RSCA-Hunauld,1735
Double aortic arch-Hommel 1737
Right aortic arch –Fioratti,Aglieti-1763
Interrupted aortic arc...
 Heart is first seen in the form of two
endothelial heart tubes-18th day of foetal life.
 Fusion results in a single tub...
 Portion ventral to foregut -
ventral aorta
 Portion dorsal to foregut-
dorsal aorta
• First arteries to appear are righ...
 After fusion of heart tubes,ventral aorta fuse
- aortic sac
 During 4th and 5th week, successive arterial
arches appear...
 Greater part of 1st &2nd arch arteries
disappear
 5th arch artery regress completely
 3rd-common carotid and prox.int....
 Portion of dorsal aorta b/w 3rd and 4th
(ductus caroticus)disappear
 Each 6th arch artery connects to the
pulmonary vas...
 Spiral septum formed in truncus in the 5th week
extends to aortic sac. Blood from pulmonary artery
goes to 6th arch arte...
 Innominate artery - right branch of
truncoaortic sac
 Right common carotid artery - right third
arch
 Right subclavian...
AORTIC ARCH ANOMALIES
 Anomalies of aortic arch to be conceptualized
as variations in regression of different
segments from a “hypothetical dou...
Normal left aortic arch is derived from
 Aortic portion of the embryonic truncus
arteriosus
 Left branch of the
truncoao...
 Left and right arch refers to which bronchus is
crossed by the arch
 Echo or angio-branching pattern of
brachiocephalic...
AORTIC ARCH ANOMALIES
CLASSIFICATION
 Abnormalities of branching.
 Abnormalities of arch position-cervical arch,
right arch
 Supernumerary arches-double aor...
 Vascular rings.
 Non-ring vascular compression.
 Non-compressive arch malformations.
 Ductal dependent arch anomalies...
 Aortic arch anomaly in which trachea and
esophagus surrounded by vascular
structures.
 The vascular structure need not ...
 Symptoms-
◦ Stridor,Pneumonia,bronchitis
◦ Reflex apnoea or choking on eating.
◦ Posture of Hyperextension of neck in in...
 The Vascular ring may be suspected from
combination of the History and plain chest
film .
 When all elements of the rin...
 3 d΄s opposite to side of arch-
diverticulum,dimple,descending aorta
 Diverticulum –large vessel from desc.aorta
giving...
 Common brachiocephalic trunk (Bovine Arch)
◦ Right innominate and left carotid
from single origin
◦ 10% of normal
◦ Comp...
The second most common pattern of human aortic arch branching has a common origin for the
innominate and left common carot...
a) Lt arch with retroesophageal RSCA
b) Lt aortic arch and retroesophageal
diverticulum of Kommerell
c) Lt aortic arch,rt....
 Also known as anomalous or aberrant right
subclavian artery .
 Bayford linked such case with history
of difficulty in s...
 Disappearance of Rt 4th arch-distal Rt
dorsal aorta becomes prox RSCA
forming its retroesophageal portion.
 Rt 6th arch...
 First vascular ring to be diagnosed during life
with barium study.
 Similar to previous except for persistent right
6th...
 Branching pattern similar to earlier
 Arch retroesophageal
 RSCA the last arch vessel .
 Descending aorta connected t...
 Plain chest film : left sided aortic arch with
right sided upper descending aorta.
 Barium esophagography : Large poste...
 RSCA arises only from rt ductus.
 Right 6th arch persists with dossolution of
right 4 th arch and right dorsal aorta.
...
 Angiography : Delayed filling of RSCA after
aortic root shoot .
 With phase encoded velocity mapping
,retrograde flow i...
 Marker of 22q11 deletion.
(Marker of CATCH 22)
 Innominate trifurcates in the neck-RSCA
travels back to thorax
 Subcla...
 A single aortic arch that crosses rt mainstem
bronchus
 13-34% in TOF
 30-40% in truncus arteriosus
 20% in pul.atres...
a) Right aortic arch-mirror image type
branching
b) Rt aortic arch with retroesophageal
diverticulum of Kommerell
c) Rt ar...
 Sequence of arch vessels-lt.innominate,rt
carotid,RSCA.
 Ligamentum lt sided.
 No vascular ring.
 Almost always assoc...
 Dissolution of left dorsal aorta distal to the
origin of left 7 th intersegmental artery
 So, left 4th arch becomes pro...
 Second most common vascular ring .
 Sequence –lt carotid,rt carotid ,RSCA,a large
retroesophageal vessel( diverticulum)...
 Symptoms of vascular ring with right sided
aortic arch on plain chest film should raise
the suspicion of this anomaly .
...
 Similar to previous one except for the
absence of retroesophageal diverticulum.
 Sequence –lt carotid,rt carotid ,RSCA,...
 Also known as circumflex right aortic arch.
 Aortic arch itself crosses midline to the left at
the level of T4 vertebra...
 Embryology : Dissolution of either left dorsal
aorta distal to takeoff of the left subclavian artery
or the left fourth ...
 Sequence : right carotid, right SCA,f/b
retroesophageal left innominate artery .
 Ductus or ligamentum connects LPA wit...
 Vessel arises exclusively from pulmonary artery via ductus
arteriosus but without connection to aorta.
 3 forms : Isola...
 Arch found above level of clavicle
 Two categories-
 1.normal branching pattern
2.anomalous subclavian artery and vasc...
o Mechanism-
-Failure of normal descent of aortic arch system
-Persistence of ductus caroticus & involution of 4th
arch-3r...
 Both rt and lt arches present.
 Both arches can be patent or one hypoplastic or
atretic(usually left)
 Persistence of ...
 Diagnosis can be made on plain chest film
when both arches are patent.
 Tracheal air column is indented by more
superio...
 First reported by Van praagh in 1969
 Double lumen aortic arch in which both
arches appear on same side of trachea.
 F...
 Defined as complete separation of ascending
and descending aorta
 Celoria and Patton classification(1959)
◦ Type A-inte...
 Type A-aorticopulmonary septal defect,TGA
 Type B- most common
a/w conotruncal anomaly with large
malaligned VSD with s...
 Type A-Involution of both dorsal aorta distal
to 4th arch and prox to persistent 6th arch
which supplies descending aort...
 AAAaa
 Type A Type B
 Present with acute cardiovascular collapse or
heart failure after closure of ductus in first
days of life.
 Absence of ...
 Surgical approch depends on the degree of
subaortic obstruction .
1.If subaortic diameter > 5 mm  primary
intracardiac ...
 Anomalous pulmonary artery branch arising
from ascending aorta in presence of a MPA
arising separately
 Anomalous RPA-
...
 LPA arises from RPA and passes b/w trachea
and esophagus-Pulmonary artery sling.
 Only Anomaly in which a major vascula...
 Systemic to pulmonary shunts are best
carried out using side with innominate artery.
 Knowledge of sidedness of aorta m...
 Aortic arch anomalies and vascular rings can
be interpreted on the basis of embryology
 With the develpoment Of MRI and...
 THANK YOU.
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
Aortic arch final.ppt
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Aortic arch final.ppt

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Aortic arch final.ppt

  1. 1. कपाकीDR. UMESH KHEDKAR D.M. CARDIOLOGY RESIDENT. LTMGH , MUMBAI.
  2. 2.  Account for 15% to 20% of all congenital cardiovascular diseases.  Result from errors in the embryologic development of the branchial arches, including errors of involution or migration, or abnormal persistence of vascular structures.  Strong associations of arch anomalies with chromosomal and genetic abnormalities are supported by studies demonstrating a deletion within chromosome 22q11associated with arch anomalies .
  3. 3.  Can be discovered when there are symptoms of airway or esophageal compression produced by vascular rings, or anomalies can be found incidentally on imaging studies obtained for other reasons
  4. 4. Anomalous RSCA-Hunauld,1735 Double aortic arch-Hommel 1737 Right aortic arch –Fioratti,Aglieti-1763 Interrupted aortic arch-Steidele-1788 Bayford,1787-dysphagia by vascular ring- coined term dysphagia lusoria. Gross,1945-first division of a vascular ring.
  5. 5.  Heart is first seen in the form of two endothelial heart tubes-18th day of foetal life.  Fusion results in a single tube with a series of dilatations - beat by 22nd day.  Bulbus cordis represents arterial end of the tube-prox part conus,distal truncus arteriosus.
  6. 6.  Portion ventral to foregut - ventral aorta  Portion dorsal to foregut- dorsal aorta • First arteries to appear are right and left primitive aorta connected to the endothelial heart tubes
  7. 7.  After fusion of heart tubes,ventral aorta fuse - aortic sac  During 4th and 5th week, successive arterial arches appear in 2nd to 6th pharyngeal arches.  Each connects ventrally to aortic sac& dorsally to dorsal aorta.
  8. 8.  Greater part of 1st &2nd arch arteries disappear  5th arch artery regress completely  3rd-common carotid and prox.int.carotid  4th –Lt.-aortic arch b/w LCCA and LSCA. ◦ Rt-prox RSCA  6TH –prox part –prox pulmonary artery ◦ distal part-ductus on left and right side involutes  Lt dorsal aorta-aortic arch distal to LSCA  Rt dorsal aorta-cranial portion-RSCA distal to 4th arch.distal portion-involutes
  9. 9.  Portion of dorsal aorta b/w 3rd and 4th (ductus caroticus)disappear  Each 6th arch artery connects to the pulmonary vascular Tree.  Portion b/w this connection and dorsal aorta- ductus arteriosus-regresses on right side
  10. 10.  Spiral septum formed in truncus in the 5th week extends to aortic sac. Blood from pulmonary artery goes to 6th arch artery,from aorta to 3rd &4th arch arteries  Dorsal aorta gives lateral intersegmental branches to body wall - 7th cervical intersegmental supplies upper limb bud
  11. 11.  Innominate artery - right branch of truncoaortic sac  Right common carotid artery - right third arch  Right subclavian - right fourth arch and right dorsal aorta proximally and right seventh intersegmental artery distally  Left carotid - left third aortic arch.  Left subclavian - left seventh intersegmental artery.
  12. 12. AORTIC ARCH ANOMALIES
  13. 13.  Anomalies of aortic arch to be conceptualized as variations in regression of different segments from a “hypothetical double arch”.  The concept of “hypothetical double aortic arch” emphasises the potential contribution of nearly all embryonic arches to components of definitive arch system.  Demonstrate possible embryologic explanations for each arch anomaly.
  14. 14. Normal left aortic arch is derived from  Aortic portion of the embryonic truncus arteriosus  Left branch of the truncoaortic sac  Left fourth arterial arch  Left dorsal aorta
  15. 15.  Left and right arch refers to which bronchus is crossed by the arch  Echo or angio-branching pattern of brachiocephalic vessels  First arch vessel that contains carotid artery opposite side of arch or Retroesophageal or isolated vessels-opp to side of arch  MRI and CT-conclusive
  16. 16. AORTIC ARCH ANOMALIES CLASSIFICATION
  17. 17.  Abnormalities of branching.  Abnormalities of arch position-cervical arch, right arch  Supernumerary arches-double aortic arch and persistent 5th arch  Interrupted aortic arch  Anomalous origin of pulmonary artery branch
  18. 18.  Vascular rings.  Non-ring vascular compression.  Non-compressive arch malformations.  Ductal dependent arch anomalies-Inturrupted aortic arch , Isolated subclavian,carotid or innominate arteries.
  19. 19.  Aortic arch anomaly in which trachea and esophagus surrounded by vascular structures.  The vascular structure need not to be patent e.g. ligamentum arteriosum.  Double aortic arch most common(40%)  Rt.Aortic arch with left.ligamentum(30%)  Aberrant RSCA(20%)  Anomalous innominate(10%)
  20. 20.  Symptoms- ◦ Stridor,Pneumonia,bronchitis ◦ Reflex apnoea or choking on eating. ◦ Posture of Hyperextension of neck in infant. ◦ Increased respiratory distress a/w intercurrent respiratory infections. ◦ Swallowing difficulty . ◦ Occasionally, in patients with associated intracardiac anomalies ,the respiratory symptoms may be mistakenly be attributed to cardiac disease.
  21. 21.  The Vascular ring may be suspected from combination of the History and plain chest film .  When all elements of the ring are patent, visualization, especially by tomographic imaging, is straightforward.  In cases where the ring is completed by an atretic segment of aorta or ligamentum arteriosum, those segments cannot be visualized with current imaging technologies.  However, these rings are recognizable by the presence of one of three “D” opposite the side of the aortic arch.
  22. 22.  3 d΄s opposite to side of arch- diverticulum,dimple,descending aorta  Diverticulum –large vessel from desc.aorta giving rise to a smaller calibre vessel with a sudden taper  Dimple –tapered blindly ending outpouching  Descending aorta in upper thorax opp.to side of arch-connected by ligamentum arteriosum
  23. 23.  Common brachiocephalic trunk (Bovine Arch) ◦ Right innominate and left carotid from single origin ◦ 10% of normal ◦ Compression of trachea possible  Separate origin of left vertebral artery ◦ 10% ◦ Prox to LSCA ◦ 3rd arch vessel smaller than 4th ◦ No Functional significance
  24. 24. The second most common pattern of human aortic arch branching has a common origin for the innominate and left common carotid arteries. K.F. Layton et al. AJNR Am J Neuroradiol 2006;27:1541- 1542 ©2006 by American Society of Neuroradiology
  25. 25. a) Lt arch with retroesophageal RSCA b) Lt aortic arch and retroesophageal diverticulum of Kommerell c) Lt aortic arch,rt.descending aorta,rt.ductus(circumflex aortic arch) d) Lt aortic arch & isolated RSCA e) Lt aortic arch with cervical origin of Rt subclavian.
  26. 26.  Also known as anomalous or aberrant right subclavian artery .  Bayford linked such case with history of difficulty in swallowing and coined term “Dysphagia Lusoria”  0.5% incidence in general population.  m.c. aortic arch anomaly  Incidence in down’s syndrome with CHD Is very high (38%).
  27. 27.  Disappearance of Rt 4th arch-distal Rt dorsal aorta becomes prox RSCA forming its retroesophageal portion.  Rt 6th arch (ductus) disappear.  Usually asymptomatic.  Barium –smaller fixed filling defect on post aspect of esophagus slanting upward to right  Angio-earlier filling of Rt carotid on aortic root injection.
  28. 28.  First vascular ring to be diagnosed during life with barium study.  Similar to previous except for persistent right 6th arch-ligamentum which completes a vasc . Ring  Prox.RSCA dilated to form diverticulum.
  29. 29.  Branching pattern similar to earlier  Arch retroesophageal  RSCA the last arch vessel .  Descending aorta connected to RPA by ligamentum-forms vasular ring  Embryology: disappearance of rt 4th arch but with left distal dorsal aorta forming definitive distal arch and passing retroesophageally to a descending aorta beginning to right of vertebral column.
  30. 30.  Plain chest film : left sided aortic arch with right sided upper descending aorta.  Barium esophagography : Large posterior indentation from retroesophageal aorta .  Angiography will confirm the course of aorta.  In symptomatic patients the Ring is divided via right thoracotomy approach.
  31. 31.  RSCA arises only from rt ductus.  Right 6th arch persists with dossolution of right 4 th arch and right dorsal aorta.  RSCA and vertebral fills from PA in foetal life  When ductus closes-retrogradely from circle of willis ◦ Vertebrobasilar insufficiency ◦ Congenital subclavian steal ◦ Absent rt arm pulse
  32. 32.  Angiography : Delayed filling of RSCA after aortic root shoot .  With phase encoded velocity mapping ,retrograde flow in the vertebral artery can be detected on MRI.  Symptomatic patients are treated with implantation of subclavian artery into aorta.
  33. 33.  Marker of 22q11 deletion. (Marker of CATCH 22)  Innominate trifurcates in the neck-RSCA travels back to thorax  Subclavian artery arises from 3rd arch in stead of 4 th .  3 rd arch being more cephalad gives origin to RSCA in the neck.
  34. 34.  A single aortic arch that crosses rt mainstem bronchus  13-34% in TOF  30-40% in truncus arteriosus  20% in pul.atresia with VSD  8-10% in transposition.
  35. 35. a) Right aortic arch-mirror image type branching b) Rt aortic arch with retroesophageal diverticulum of Kommerell c) Rt arch with retroesophageal LSCA d) Rt arch with Lt desc aorta and Lt ligamentum
  36. 36.  Sequence of arch vessels-lt.innominate,rt carotid,RSCA.  Ligamentum lt sided.  No vascular ring.  Almost always associated with CHD (48% TOF)
  37. 37.  Dissolution of left dorsal aorta distal to the origin of left 7 th intersegmental artery  So, left 4th arch becomes proximal left subclavian artery.  Left Sixth arch persists- left ductus arises from underside of left innominate artery and passes to LPA .  Alternatively right ductus persists giving true mirror image of normal.
  38. 38.  Second most common vascular ring .  Sequence –lt carotid,rt carotid ,RSCA,a large retroesophageal vessel( diverticulum) from which LSCA arises  Lt ligamentum completes the ring  Disappearance of Lt 4th arch and persistence of 6th arch  Should be differentiated from rt aortic arch with retroesophageal subclavian artery.
  39. 39.  Symptoms of vascular ring with right sided aortic arch on plain chest film should raise the suspicion of this anomaly .  Barium study reveals a large posterior indentation on the esophagus.  Branching pattern of arch vessels on echo.  Angiography reveals characteristic branching pattern and abrupt change in calibre from diverticulum to subclavian artery.  MRI ideal for diagnosis .  Surgical division of ductus in symptomatic patients via left thoracotomy.
  40. 40.  Similar to previous one except for the absence of retroesophageal diverticulum.  Sequence –lt carotid,rt carotid ,RSCA, retroesophageal LSCA.  Ductus is rt sided.  No vascular ring.  Involution of left 4th and 6th aortic arches.  Associated with conotruncal anomalies .  Higher incidence of 22q11 deletion.
  41. 41.  Also known as circumflex right aortic arch.  Aortic arch itself crosses midline to the left at the level of T4 vertebral body -connects to lt ductus to form vascular ring  Sequence –lt innominate,rt carotid ,RSCA or lt carotid,f/b right carotid,right subclavian,finally left subclavian.  Aortic arch is retroesophageal and not the subclavian artery.
  42. 42.  Embryology : Dissolution of either left dorsal aorta distal to takeoff of the left subclavian artery or the left fourth arch. Persistent left sixth arch connects to the left sided dorsal aorta completing vascular ring .  Barium study :downward slanting left oesophageal indentation .  Mobilisation of retroesophageal aortic segment and reanastomosis of asc and dec aorta using tube graft may be needed in symptomatic adults in addition to simple division of ligamentum.
  43. 43.  Sequence : right carotid, right SCA,f/b retroesophageal left innominate artery .  Ductus or ligamentum connects LPA with base of innominate a. completing vascular ring.  Embryology : dissolution of left branch of truncoaortic sac and left 4 th arch .The left dorsal aorta supplies left 7th IS artery and left 3 rd arch.  Clue for diagnosis is single carotid artery arising from proximal aorta.  In symptomatic patients surgical division of ligamentum with implantation of innominate artery to ascending aorta is required.
  44. 44.  Vessel arises exclusively from pulmonary artery via ductus arteriosus but without connection to aorta.  3 forms : Isolation of LSCA (m.c.),Isolation of left carotid and isolation of Left innominate .  CHD in more than 50% (m.c. TOF).  Presentation: diminished pulse amplitude or blood pressure in left arm , subclavian steal syndrome,pulmonary artery steal (if duct patent)  The dignosis should be suspected in pt with right sided aortic arch with diminished pulse amplitude or blood pressure in left arm .  Delayed filling of LSCA via vertebral artery during aortic arch shoot confirms diagnosis.
  45. 45.  Arch found above level of clavicle  Two categories-  1.normal branching pattern 2.anomalous subclavian artery and vascular ring with descending aorta contralateral to arch or retroesophageal diverticulum.  2nd group-divided according to carotid origin (bicarotid trunk or separate origin of ext & int carotid)  First group usually has left sided arch while second group has right sided.  Separate origin of vertebral artery can be seen in both groups.
  46. 46. o Mechanism- -Failure of normal descent of aortic arch system -Persistence of ductus caroticus & involution of 4th arch-3rd arch becomes definitive aortic arch with separate origin of ext &int carotid from it. oPresentation : - Pulsatile mass in supraclavicular fossa or the neck. - Symptoms of vascular ring - Subclavian steal in patients with stenosis or atresia of LSCA . oPresumptive diagnosis can be made by notation of loss of femoral pulse during brief compression of the mass.
  47. 47.  Both rt and lt arches present.  Both arches can be patent or one hypoplastic or atretic(usually left)  Persistence of both rt and lt 4th arch which join TA sac to their respective dorsal aortae  Only one 6th remain.  Symmetric origin of 4 arch vessels from respective arches when both patent  Rarely a/w other CHD, when present-TOF most common.  Form complete vascular rings.  When both arches are patent, rings typically tight and present with sridor in first week of life.
  48. 48.  Diagnosis can be made on plain chest film when both arches are patent.  Tracheal air column is indented by more superior right sided arch and inferior left sided arch.  Confirmation with further imaging is important to identify atretic segment.  Surgical division of ring in symptomatic.
  49. 49.  First reported by Van praagh in 1969  Double lumen aortic arch in which both arches appear on same side of trachea.  Frequently associated with CHD; however can be incidental finding without clinical significance .  2 common sub categories- ◦ Subway vessel beneath normal arch(4th arch)that extend from innominate to take off of LSCA ◦ Double lumen aortic arch with atresia of superior arch with patent inferior arch-common origin of all brachiocephalic vessels from asc.aorta
  50. 50.  Defined as complete separation of ascending and descending aorta  Celoria and Patton classification(1959) ◦ Type A-interruption distal to SCA that is ipsilateral to 2nd carotid artery ◦ Type B-interruption b/w 2nd carotid and ipsilateral subclavian ◦ Type C-interruption b/w carotids.  Each of the types subcategorised to 3 types ◦ 1.without retroesophageal or isolated subclavian artery ◦ 2.with retroesophageal subclavian artery ◦ 3. with isolated subclavian artery
  51. 51.  Type A-aorticopulmonary septal defect,TGA  Type B- most common a/w conotruncal anomaly with large malaligned VSD with subaortic obstruction, DiGeorge syndrome.  Type C-rare  Interrupted rt arch seen only in DiGeorge syndrome.
  52. 52.  Type A-Involution of both dorsal aorta distal to 4th arch and prox to persistent 6th arch which supplies descending aorta .  Type b-Involution of one 4th arch and one dorsal aorta b/w 4th and 6th.  Type C-Involution of one limb of truncoaortic sac,associated proximal 3 rd arch and entire 4 th arch with persistence of dorsal aorta between 3rd and 4 th arch.
  53. 53.  AAAaa  Type A Type B
  54. 54.  Present with acute cardiovascular collapse or heart failure after closure of ductus in first days of life.  Absence of all limb pulse with strong carotid pulse suggest type B with anomalous subclavian.  2 D echo is most important diagnostic tool .  3 D reconstructive MRI is useful for identifying branching pattern and site of inturruption.
  55. 55.  Surgical approch depends on the degree of subaortic obstruction . 1.If subaortic diameter > 5 mm  primary intracardiac repair. 2.If subaortic diameter < 3mmbypass subaortic region – associate MPA with ascending aorta using homograft augmentation to complete aortic reconstruction.  Aortic arch is reconstructed by liberal dissection around two arch components with direct anastomosis of two ends.
  56. 56.  Anomalous pulmonary artery branch arising from ascending aorta in presence of a MPA arising separately  Anomalous RPA- ◦ More common ◦ Embryonic branch pul.artery joins rt side of TA sac,but fails the leftward migration to join MPA before septation ◦ High incidence of aorticopulmonary septal defect  Anomalous LPA ◦ a/w TOF in 74% ◦ Embryonic branch pul.artery fails to join TA sac  CCF in infancy f/b early development of pulmonary vascular disease.
  57. 57.  LPA arises from RPA and passes b/w trachea and esophagus-Pulmonary artery sling.  Only Anomaly in which a major vascular structure passes between trachea and esophagus.  Tracheal compression-Severe respiratory distress and stridor,Milder forms may exists  Isolated anomaly, rarely a/w TOF  Anterior indentation on barium swallow.  Bronchoscopy needed prior to surgery to rule out complete cartilagenous ring .
  58. 58.  Systemic to pulmonary shunts are best carried out using side with innominate artery.  Knowledge of sidedness of aorta may be very useful in the repair of eosophageal atresia or tracheo-esophageal fistula.  Anatomical variations or anomalies in brachiocephalic arteries my pose difficulty in Carotid artery stenting as well as may increase complication rates..
  59. 59.  Aortic arch anomalies and vascular rings can be interpreted on the basis of embryology  With the develpoment Of MRI and CT, 3-D reconstruction is possible.  Intervention required only when symptomatic or when a/w other cardiac anomalies.
  60. 60.  THANK YOU.

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