Division of the more often-identified vascular rings that cause airway obstruction has been described elsewhere, often and in detail. These anomalies are listed in Chapter 6, "Congenital and Acquired Tracheal Lesions in Children." Also noted there is the less-common occurrence of "circumflex aorta." Brief technical note will be made here, however, of the highly unusual compression, described in Chapter 6, "Congenital and Acquired Tracheal Lesions in Children," which is due to right aortic arch, right descending aorta, liga-mentum arteriosum, Kommerell's diverticulum, and aberrant left subclavian artery (Figure 32-7A). The aortic arch is usually high, and bends sharply before descending in a "hairpin" configuration on the right side, directly behind the ascending arch. The distance between the sternum and vertebral column is diminished, sometimes with mild pectus excavatum deformity. This leaves little space between the ascending and figure 32-6 Correction of tracheal obstruction due to severe straight back syndrome, with mild pectus excavatum. A, Sagittal diagram illustrating points of tracheal compression. The tracheal lumen is diagrammed at the right ofeach point of obstruction. 1) The proximal sternum squeezes the trachea against the vertical vertebral column. Note the minimal distance between the sternum and the vertebrae. 2) The brachiocephalic artery compresses the trachea similarly. 3) The lower intrathoracic trachea is splayed against the vertebral column in this patient. The top of the sternum was resected and the balance of the manu-brium thinned and replaced in this young patient (dashed lines). Stippled areas of sternum were removed. B, Postoperative correction. Obstructing proximal sternum and compressive brachio-cephalic artery have been removed. The artery was transplanted laterally and the lower trachea was splinted with Marlex. Shallow osteotomy first removed vertebral prominences behind the splayed lower trachea. C, D, The brachiocephalic artery was lengthened with a graft and rerouted lower and lateral to the trachea. These figures describe correction of a highly unusual problem, which apparently may present variously.
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