Aortic arch and frozen elephant trunk repair of a right-sided aortic arch with pseudoaneurysm

A 53 year old male with a history of vascular ring repair secondary to a right sided aortic arch with retroesophageal subclavian artery and ligamentum arteriosum to the descending thoracic aorta presented to our institution with a large aortic pseudoaneurysm of the distal aortic arch. Computed tomography demonstrated a right sided aortic arch with a 5.8 cm pseudoaneurysm arising from the distal arch in the area of his previously divided ligamentum. The patient underwent a successful two-stage repair including a left carotid to subclavian bypass followed by total arch replacement with frozen elephant trunk. He recovered well postoperatively and computed tomography showed complete repair of the pseudoaneurysm with patent bypass graft.

Kommerell’s diverticulum with right-sided aortic arch and anomalous origin of neck vessels: Uncommon imaging finding in neonate with cyanosis

Kommerell diverticulum is a rare developmental anomaly of aortic arch. It is most frequently seen with right-sided aortic arch and aberrant left subclavian artery or ligamentum arteriosum, which have a significant role in completing a vascular ring. However, aberrant origin of neck vessels along with it is not commonly seen. The signs and symptoms vary depending on the severity. The paediatric patients usually present early due to compression of mediastinal structures such as trachea or oesophagus.

Gross Anatomy of the Heart of Mature Philippine Water Buffalo (Bubalus bubalis L.)

The gross morphology of the heart of mature Philippine water buffalo was described by determining the weight, length, width and circumference; measured the average external circumference of the pulmonary veins and artery, cranial and caudal vena cava and the aorta; determined the presence and location of ligamentum arteriosum; measured the thickness of the atrial and ventricular wall; described the components of the left and right atrioventricular valves, pulmonary valves and the aortic valves; determined the location and measured the length of trabeculae septomarginalis and determined the location of the os cordis. Hearts of ten mature Philippine water buffalo of both sexes were collected from abattoirs of Cabanatuan City. The absolute and relative weights of the heart were measured using digital weighing scale. Different dimensions like circumferences, length, and width of the heart; the external circumferences of major blood vessels; and the thickness of the wall of heart were determined using measuring tape and Vernier caliper. The number of cusps present in the left and right atrioventricular, pulmonary, and aortic valves was counted and the presence of ligamentum arteriosum was documented. Radiograph was used to determine the presence and location of os cordis. All of the hearts studied were pointed and bilaterally flattened. The base of the heart is markedly surrounded with fatty tissues. The mean absolute weight is 2.42 kg. The heart has a mean dimension of 21.71 cm x 17.49 cm. The mean circumference at the level of the coronary groove, middle and apex were 48.41 cm, 44.10 cm and 20.57 cm, respectively. An average of four pulmonary veins was documented to be present. The right ventricle has a constant three papillary muscles and three cusps while the left ventricle has a constant two papillary muscles and two cusps. The number of cusps of both pulmonary valve and aortic valve was three. Ligamentum arteriosum was present in all samples and it is located between the pulmonary trunk and aorta. The os cordis which is located at the aortic fibrous ring is present in all heart of Philippine water buffalo examined.

Congenital kinking of aorta – A rare aortic arch anomaly

Congenital kinking of aorta or pseudocoarctation is a rare anomaly of the aortic arch with elongation and kinking of aorta at the level of ligamentum arteriosum. This anomaly is not a true coarctation as there is no significant hemodynamic obstruction or pressure gradient across the lesion. We report two cases with this anomaly diagnosed during the evaluation for incidental finding of murmur. Both patients had flow gradient across the kinked segment of aorta by echocardiography but did not require any intervention. Long term complication is aneurysmal dilatation and rupture beyond the kinked segment. Computed tomography of the aorta is a simple noninvasive diagnostic modality for the definitive diagnosis. Surgical repair should be performed for all symptomatic individuals. Regular periodic follow up is mandatory for all asymptomatic patients.

Nerve at risk: anatomical variations of the left recurrent laryngeal nerve and implications for thoracic surgeons

OBJECTIVES Recurrent laryngeal nerve (RLN) injury during thoracic surgery may result in life-threatening postoperative complications including recurrent aspiration and pneumonia. Anatomical details of the intrathoracic course are scarce. However, only an in-depth understanding of the anatomy will help reduce nerve injury. The aim of this study was to assess the anatomic variations of the intrathoracic left RLN. METHODS Left-sided vagal nerves and RLN were dissected in 100 consecutive Caucasian cadavers during routine autopsy. Anatomical details were documented. Available demographic data were assessed for possible correlations. RESULTS All nerves were identified during dissection. Variant courses were classified in 3 different groups according to the level at which the RLN separated from the vagal nerve: above the aortic arch, level with the aortic arch and below the aortic arch. We found 11% of RLN separating above the aortic arch and crossing the aortic arch at a considerable distance to the vagal nerve. In 48% of the RLN, the nerve split off when it was level with the aortic arch, and 41% of the RLN leave the vagal nerve in a perpendicular direction below the aortic arch. All nerves crossed the ligamentum arteriosum on the posterior side. No gender-specific differences were observed. CONCLUSIONS Mediastinal lymph node dissection in left-sided lung cancer patients puts the RLN at risk. With more detailed anatomical knowledge about its course, it is possible to avoid risking the nerve. Visualization will help protect the nerve.

Ligamentum arteriosum calcification that presented as an esophageal perforation caused by duck bone ingestion

Ligamentum arteriosum calcification is the calcification or ossification of arterial ligaments. However, on computed tomography images, ligamentum arteriosum calcification is often mistaken for esophageal perforation when a patient has a medical history of foreign body ingestion. Ligamentum arteriosum calcification is uncommon in clinical practice. In this case report, we confirm the presence of this condition intraoperatively, which has seldom been reported previously. Increased awareness of the clinical characteristics of this uncommon disease can help thoracic surgeons with proper patient management.