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figure 32-7 Correction of obstruction from an unusual vascular ring, termed "hairpin" aorta, seen in patients with diminished distance between the sternum and vertebrae. A, The ascending aorta (AA) is on the right and also descends (DA) on the right, leaving only a narrow space underneath the arch between the ascending and descending limbs. Left subclavian (LS) artery is anomalous, arising from a Kommerell's diverticulum (DK) and encircles trachea (T) and esophagus (E). Ligamentum arteriosum (LA) completes the ring to the pulmonary artery (PA). Right (RCC) and left (LCC) carotid arteries branch anteriorly and the right subclavian (RS) arises from the arch. Our patients variously had undergone division of LA, LS, and excision ofDK without relief of tracheal obstruction. B, Correction required removal of a Kommerell's diverticulum, division of the ligamentum arteriosum and left subclavian (LS), and reimplantation of the LS into the left carotid artery. If aortopexy (of one or both limbs of the arch) gave insufficient relief (observed bronchoscopically), aorto-aortic graft was performed below the hilum and the aorta divided, as shown. The limbs were pexed to upper ribs anteriorly and posteriorly.

descending aorta. The airway is compressed in this vise, with the contributing factor of Kommerell's diver-ticulum and an anomalous left subclavian artery.

A small number of patients have been seen with this problem and treated. Prior division of the liga-mentum, division of the anomalous subclavian artery, and excision of the diverticulum in several patients had failed to relieve the severely symptomatic tracheal compression. Variations in the small group of patients seen makes it difficult to recommend a categorical procedure. However, opening the narrow space between the aortic limbs has proved effective, when excision of the aortic diverticulum, reimplantation of the retroesophageal subclavian artery, and division of the ligamentum arteriosum failed to provide relief of the airway compression.

The anatomy must be carefully delineated by imaging (see Figure 6-15 in Chapter 6, "Congenital and Acquired Tracheal Lesions in Children") and account is taken of any prior surgical treatment. Through right thoracotomy, the aberrant left subclavian artery is divided and tentatively closed. The Kommerell's diverticulum is excised and the ligamentum is divided. Then, the degree of airway relief obtained is observed by flexible bronchoscopy via the endotracheal tube. The aortic arch is next tentatively retracted with slings to determine (by bronchoscopy) whether aortopexy alone will be sufficient to relieve the obstruction completely. If not, a synthetic graft is placed between the ascending and descending aorta, beneath the right hilum. The aortic arch is divided at its apex, and each limb is pexed as necessary to an adjacent upper rib anteriorly and posteriorly (Figure 32-7B). If retracting the aorta alone is sufficient, the arch is pexed with slings to maintain the space so enlarged. Broad slings of Goretex are used to avoid a potential cutting effect on the aorta. It is important to assess the effect on airway compression broncho-scopically as each step is completed. The anomalous subclavian artery is finally anastomosed to the left carotid artery through a cervical incision (see Figure 32-7B).

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