Accepted for publication July 26, 2013.

Address correspondence to Dr Talwar, Department of Cardiothoracic andVascular Surgery, All India Institute of Medical Sciences, New Delhi-110029, India; e-mail: sachintalwar@hotmail.com.

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interposition graft [5]. Median sternotomy is the exposureof choice for accessing innominate artery injuries [1, 5, 6].However, with this approach, one risks entering, or beingunable to access, an uncontrolled mediastinal hematoma,which may lead to exsanguination [1]. Because of the highcomplication rate seen in open surgical repair of suchinjuries, endovascular intervention is being increasinglyintroduced in the hemodynamically stable patient withinjury to the thoracic aorta and its branches, providingan opportunity for decreased surgical morbidity [1].Although this remains an increasingly utilized method ofintervention with positive results, placement of prostheticstents in young trauma patients presents many unan-swered questions [1]. One must keep in mind the lack ofpediatric-size stent grafts and delivery systems, in addi-tion to the question of possible graft migration secondaryto expected vessel growth in the pediatric population [2].Consequently, open repair remains the current standardof care for pediatric thoracic aortic injury and great vesselinjuries [2].

Although unilateral hemothorax has been suggested asan indicator of injury, it is not uncommon for these pa-tients to present with minimal outward signs of injurysuch as neurologic deficit or extremity ischemia [7, 8].Therefore, patients presenting with mechanism of injuryindicating a high likelihood of thoracic outlet injury needto be treated with a high index of suspicion and beevaluated rapidly with physical examination and radio-logic survey [8]. Hemodynamically stable patients shouldbe promptly evaluated with contrasted CT scan of thechest, and patients with equivocal studies may benefitfrom repeat CT with three-dimensional reconstructions[2]. Angiography may also be utilized in the diagnosis ofthoracic outlet injury to delineate specific details of theinjury, collateral flow, and distal perfusion; however, therisk of iatrogenic injury during vascular access increasesin younger patients and may even exacerbate the injury[2]. Computed tomography has the advantages of thecapability to detect intraluminal thrombus, to distinguishbetween true and false lumens in dissections, and todetect local effects of the hematoma or aneurysm againstthe adjacent structures [3].

Pediatric vascular injuries remain a clinical subjectinspiring much debate in the absence of high-qualityprospective data. These injuries remain poorly de-scribed and underrepresented in the current literature,especially injuries to the great vessels. Given the paucityof information, the care of pediatric vascular injury re-mains a rapidly evolving field, no longer focusing onexpectant management and instead encouraging a moreaggressive approach to repair.

In summary, recent experience has shown that combathospitals and civilian trauma centers alike must be pre-pared to treat pediatric victims of blast events. Althoughthe results of individual case studies such as this mayportend a favorable outcome to aggressive resuscitationand surgical management of these injuries, moreencompassing and systematic investigation of pediatricvascular trauma is imperative. Given the low incidence ofthese types of injuries and the limited experience of most

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

surgeons in this area, a national pediatric vascular injuryregistry would lay the foundation for defining optimalapproaches to management in such complex cases.

DISCLAIMER: The opinions expressed in this document aresolely those of the authors and do not represent an endorsementby or the views of the United States Air Force, the United StatesArmy, the Department of Defense, or the United StatesGovernment.

References

1. Blattman SB, Landis GS, Knight M, et al. Combined endo-vascular and open repair of a penetrating innominate arteryand tracheal injury. Ann Thorac Surg 2002;74:237–9.

2. Cannon JW, Peck MA. Vascular injuries in the young. Per-spect Vasc Surg Endovasc Ther 2011;23:100–10.

3. Hirose H, Moore E. Delayed presentation and rupture of aposttraumatic innominate artery aneurysm—case report andreview of literature. J Trauma 1997;42:1187–95.

4. Hoffer EK. Endovascular intervention in thoracic arterialtrauma. Injury Int J Care Injured 2008;39:1257–74.

5. McLean TR, McManus RP. Penetrating trauma involving theinnominate artery. Ann Thorac Surg 1991;51:113–5.

6. Mousa AY, Batsides GP, Vogel TR. Delayed presentation oftraumatic innominate artery injury. J Vasc Surg 2010;51:1014.

7. Pate JW, Cole FH, Walker WA, et al. Penetrating injuries ofthe aortic arch and its branches. Ann Thorac Surg 1993;55:586–92.

8. Richardson JD, Smith JM, Grover FL, et al. Management ofsubclavian and innominate artery injuries. Am J Surg1977;134:780–4.

Unusual Compression of theRight Pulmonary Artery by theAortic ArchSachin Talwar, MCh, Saurabh Kumar Gupta, DM,Subramanian Muthukkumaran, MS,Madhan Kumar Murugan, MD, and Balram Airan, MCh

Cardiothoracic Centre, All India Institute of Medical Sciences,New Delhi, India

Compression of the right pulmonary artery is unusual.We describe a patient with a double-outlet right ventricle,a ventricular septal defect, and pulmonary stenosis inwhom the right pulmonary artery was compressed by aright-sided aortic arch. The condition was successfullymanaged during surgical correction.

(Ann Thorac Surg 2014;97:1790–2)� 2014 by The Society of Thoracic Surgeons

ompression of the right pulmonary artery (RPA) is

Cunusual. We describe a patient with double-outletright ventricle, ventricular septal defect (VSD) and pul-monary stenosis in whom the RPA was compressed by a

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right-sided aortic arch. The condition was successfullymanaged during surgical correction.

A 6-month-old male infant weighing 4 kg presentedwith cyanosis since 2 months of age. On examination, thechild had central cyanosis (SpO2 65%) and clubbing.Cardiac examination revealed normal S1, single S2, and agrade 2/6 ejection systolic murmur. A roentgenogram ofthe chest showed a normal-sized heart with oligemic lungfields. Echocardiography revealed a large malalignedsubaortic VSD with aortic override and aortomitraldiscontinuity, suggesting double-outlet right ventricle,severe pulmonary stenosis with a gradient of 68 mm Hg,and right ventricular hypertrophy. The anatomy of thebranch pulmonary arteries (PA) was not clear. Subse-quent computed tomographic (CT) angiography showednonconfluent PAs. The main PA continued as the RPA,and the LPA was instead connected to a closing remnantof the patent arterial duct arising from the left commoncarotid artery.

Because of significant systemic desaturation withdisconnected LPA in a small child, pulmonary valveballoon dilatation was performed. The catheter angio-gram confirmed the findings of echocardiography(Fig 1). The main PA continued as the RPA. The LPAwas not seen. Postprocedure angiography of the RPAshowed external compression of the RPA at the mid-segment (probably by the aortic arch). There wasimprovement in systemic saturation from 65% to 80%.However, this was short lasting; hence, early surgicalcorrection was planned. Unfortunately, the patient waslost to follow-up for 1 year, therefore, surgical correctioncould be performed only when he was 1.5 years of age.Before the operation, repeated CT angiography wasperformed to assess the size of the PAs (Figs 2A, 2B).Interestingly, as also seen in the catheter angiogram, theRPA showed an unusually high takeoff from an elon-gated MPA that resulted in superior displacement ofthe RPA, bringing it closer to the aortic arch. Thecompression of the RPA by the aortic arch was evident;

the narrowest portion at the site of compressionmeasured 3 mm, and the distal RPA measured 6 mm.The mediastinal portion of the LPA was absent, andthe hilar LPA measured 6 mm. The descendingthoracic aorta measured 9 mm at the diaphragm(McGoon’s ratio 1.3).The surgical challenges in this patient were releasing

the extrinsic compression of the RPA, establishing con-tinuity between nonconfluent Pas, and performingconcomitant intracardiac repair. After sternotomy, theaorta and the MPA were separated from each other, andthe PAs were dissected and mobilized up to the lunghilum. Standard cardiopulmonary bypass (CPB) at 28�Cwas established by aortobicaval cannulation. After theaorta was cross-clamped, antegrade cold blood car-dioplegia was delivered. At the site of compression bythe aortic arch, the RPA measured only 3 mm, whereasdistally it measured approximately 7 mm. The ascendingaorta was transected, and a Lecompte maneuver [1] wasperformed to bring the RPA anterior to the aorta. Theligamentum arteriosum was divided, and the LPA wasrelocated to the MPA in an end-to side anastomosis,restoring the continuity between both the PAs. The RPAwas incised across the area of stenosis and wasaugmented with a pericardial patch. The aorta wasreconstructed by direct anastomosis after excision of a4-mm circumferential segment. The right atrium wasopened, and resection of the infundibular muscle bun-dles was performed, followed by closure of the VSD withuse of a patch. The right atrium was closed, and after atransannular incision, the right ventricular outflow tractwas augmented with an autologous pericardial patch.The aortic cross-clamp was released, and the patient wasuneventfully weaned from CPB with minimal inotropicsupport. The aortic cross-clamp time and CPB time were95 minutes and 150 minutes, respectively. The childrecovered uneventfully except for an episode of extu-bation failure. He was discharged from the hospitalon the 18th day. Postoperative echocardiograms and aCT angiogram (Figs 2C, 2D) demonstrated satisfactory

Fig 1. Catheter angiogram in right ventricu-lar outflow in (A) anteroposterior and (B)lateral views showing elongated mainpulmonary artery (MPA) continuing as rightpulmonary artery (RPA). The RPA after asharp angulation at origin descends downunder the right aortic arch, causing extrinsiccompression (white arrow) of themidsegment. The left pulmonary artery is notvisualized. (Asc Ao ¼ ascending aorta.)

Fig 2. (A, B) Preoperative computedtomographic angiography. (A) Volumerendered technique reformat in posterioroblique projection. (B) Maximum intensityprojection reformat in oblique view showingsignificantly compressed right pulmonaryartery (RPA) (blue arrow) between the aortaanteriorly and the tracheal bifurcation(yellow star). The caliber of the RPA ismarkedly reduced at this location; however,the distal RPA is normal. As AO ¼ ascendingaorta; MPA ¼ main pulmonary artery;DTA ¼ descending thoracic aorta; LSCA ¼left subclavian artery. (C, D) Postoperativecomputed tomographic angiography. (C)Volume rendered technique reformat inanterior oblique projection. The arrow showsthe right pulmonary artery that has beentranslocated anterior to the aorta. (D)Maximum intensity projection reformat inaxial oblique view, showing postoperativealtered anatomy of the RPA, place anterior tothe aorta; the RPA compression is relieved,and the pulmonary arteries are confluent.Yellow arrow indicates reconstructed RPA.(LPA ¼ left pulmonary artery; SVC ¼superior vena cava.)

Accepted for publication July 22, 2013.

Address correspondence to Dr Bobylev, Division of Cardiothoracic,Transplantation, and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str 1, Hannover 30625, Germany; e-mail: bobylev.dmitry@mh-hannover.de.

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repair. At 1-year follow-up, the child is doing well andno longer needs cardiac medication.

Comment

The close proximity of the RPA to the aorta theoreticallyrenders it to compression by the latter. Although unheardof in the pediatric age group, dissecting aneurysms of theaorta have been described as producing acute occlusionof the RPA in adults [2].

The unusual aspect of this particular case is the orien-tation and extrinsic compression of the RPA. Althoughthe exact mechanism can be debated, it is likely causedby abnormally high takeoff from the MPA and the sharpangulation the RPA must take to reach into the right lung.The aortic arch, being on the right side along witha relatively posterior location of the ascending aorta(Fig 1B), possibly contributed to the compression.Considering all these factors, including the abnormal lieand angulation of the RPA, it was logical to choose amethod of repair that entailed not only straightening theangulation but also relocating the RPA anterior to theaorta. Both these objectives were accomplished by theLecompte maneuver [1], which essentially had the effectof bringing the RPA in front of the aorta and lifting itanteriorly, thereby straightening the acute angle. Apartfrom the unusual anatomic condition, this report alsoadds to an expanding list of indications of the LeComptemaneuver in operations other than the arterial switchoperation. To the best of our knowledge, a similar patienthas not been reported in the English literature.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

References

1. Lecompte Y, Zannini L, Hazan E, et al. Anatomic correction oftransposition of the great arteries. J Thorac Cardiovasc Surg1981;82:629–31.

2. De Silva RJ, Hosseinpour R, Screaton N, Stoica S,Goodwin AT. Right pulmonary artery occlusion by an acutedissecting aneurysm of the ascending aorta. J CardiothoracSurg 2006;1:29.

Semilunar Valve ReplacementWith Decellularized HomograftAfter Damus-Kaye-StanselAnastomosis and Fontan ProcedureDmitry Bobylev, MD, Thomas Breymann, MD,Dietmar Boethig, MD, Axel Haverich, MD, andMasamichi Ono, MD, PhD

Divisions of Cardiothoracic, Transplantation, and VascularSurgery, and Pediatric Cardiology and Intensive Care Medicine,Hannover Medical School, Hannover, Germany

We describe a patient in whom severe neoaortic(anatomic pulmonary) valve regurgitation developed

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