figure 6-8 Congenital stenosis with irregular, confluent plates of cartilage, a very rare malformation. A, Resected specimen. Note the absence of visible rings externally, in comparison with the usual structure of congenital stenosis shown in Figure 6-7A. A cross-sectional specimen below clearly shows completely circular cartilage. B, Luminal surface of A. Note the irregular "haustra" of disordered cartilage plates covered with mucosa.

esophagus. In most of these patients, completely circular "O" rings of cartilage are found in the stenotic segment. The length of tracheal stenosis most often extends beyond the region of the anomalous pulmonary artery sling. Where stenosis is not present, there may instead be a malacic segment at the level of the artery.19 The artery alone can also obstruct the right main bronchus.

Division of the anomalous pulmonary artery and reimplantation into the main pulmonary artery anterior to the trachea fails to relieve the airway obstruction when stenosis or malacia are present.19,20 The ligamentum arteriosum, which effectively makes this a ring, is also divided. Sometimes, it has been possible to resect the stenotic tracheal segment and shift the artery anteriorly prior to anastomosing the trachea, as suggested might be possible by Grillo.21,22 This is desirable because of a high rate of stenosis of reimplanted

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