Neonatal tracheal reconstruction in tracheomalacia secondary to double aortic arch

Introduction: Developmental abnormalities of the aortic arch system result in a variety of vascular anomalies. Double aortic arch (DAA) is a complete form of vascular ring causing tracheoesophageal compression and thus, is a rare but treatable causes of stridor in the newborn. This video shows our surgical management of a newborn with localised tracheomalacia secondary to DAA that presented as neonatal respiratory distress. Background: A newborn was referred to our unit for respiratory distress. Echocardiography and MRI showed left dominant DAA and complete vascular ring with tracheal obstruction. The right common carotid and right subclavian arteries originated from the right sided arch, while the left common carotid and left subclavian arteries originated from the left sided arch. He underwent elective surgery on 15th day of life. Surgical repair was approached through median sternotomy and normothermic, beating heart cardiopulmonary bypass was used. The ligamentum arteriosum was found between the left sided aortic arch and the pulmonary trunk. It was then ligated and divided. Division of the right arch was performed distally, closed to its junction with the descending aorta. Its ends were oversewn and then further dissected from underlying mediastinal tissues, resulting in immediate relief of the complete vascular ring. Intraoperative tracheobronchoscopy showed a localised tracheomalacia and thus, subsequent resection of the distal trachea was carried out. Both tracheal ends were end-to-end reanastomosed and tracheobronchoscopy showed no further obstruction. The postoperative course was uneventful and patient was extubated on the fourth postoperative day. Discussion: Surgical division of the complete vascular ring was indicated in patients with clinical symptoms as result from the compressive effects of the adjacent airway or part of the oesophagus. Complete decompression was accomplished by dividing the minor arch and patent ductus or ligamentum arteriosus. Patient with coexisting localised tracheomalacia may benefit from a resection of the severely malacic tracheal segment and subsequent tracheal reconstruction.