Video-Assisted Thoracoscopic Division of Vascular Rings in Pediatric Patients CURT S. KOONTZ, M.D.,* AMINA BHATIA, M.D.,* JOE FORBESS, M.D.,† MARK L. WULKAN, M.D.* From the Divisions of *Pediatric Surgery and †Pediatric Cardiothoracic Surgery, Joseph B Whitehead Department of Surgery, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia Vascular rings are usually repaired via left thoracotomy. We report our series of pediatric patients with vascular rings that were repaired thoracoscopically. From February 2002 to September 2004, 13 patients underwent video-assisted thoracoscopic surgical techniques (VATS) division of their vascular ring. Chest magnetic resonance arterography (MRA) and/or computed tomographic ar- teriography (CTA) were used to evaluate the vascular ring in most patients. Patients were chosen for VATS repair based on surgeon’s choice and type of vascular ring. Data are expressed as mean ± SD. The Children’s Healthcare of Atlanta Institutional Review Board approved this retrospec- tive chart review. Age and weight was 1.5 ± 1.8 years (range: 4 months–17 years) and 16.0 ± 12.5 kg (range: 6.0–22.1 kg), respectively (n = 13). Associated diseases included congenital heart disease (n = 2). Symptoms included respiratory complaints (n = 6), dysphagia (n = 2), dysphagia and shortness of breath (n = 1), pneumonia (n = 2), tracheal deviation (n = 1), and one patient was asymptomatic. Vascular ring types included double aortic arch (n = 4) and right aortic arch with an aberrant left subclavian artery and a left ligamentum arteriosum (n = 9). Operating time was 70 ± 20 minutes (range: 46–122 minutes). One patient had to be opened because of a large arch. Length of stay was 1.9 ± 0.9 days (range: 1–3 days). There were no complications, and all patients improved clinically at follow-up. Thoracoscopic repair of certain types of vascular rings seems to be safe and effective in children. More patients, however, need to be studied. A VASCULAR RING IS A RELATIVELY UNCOMMON con- genital vascular defect that is a result of erroneous embryological development of the branchial arches and can form a complete or incomplete ring around the esophagus and trachea. The two most common types of complete vascular rings are the double aortic arch and the right arch with an aberrant left subclavian artery and a left ligamentum arteriosum. These com- prise 85–95 per cent of the cases. 1 The complete vas- cular ring encircles the trachea and esophagus, causing varying degrees of compressive symptoms. Common symptoms include stridor, cyanosis, respiratory dis- tress, apnea, and high-pitched brassy cough. Addi- tional findings include a history of asthma, recurrent pneumonia, dysphagia, or difficulty feeding. 1 The division of most types of vascular rings is tra- ditionally performed via a left thoracotomy 2, 3 and was first described by Dr. Robert E. Gross in 1945. 4 With the refinement of video-assisted thoracoscopic surgi- cal techniques (VATS) and miniaturization of instru- ments and video equipment, more procedures are be- ing attempted thoracoscopically in children. In 1993, Burke et al. described the first VATS vascular ring division and subsequently reported a series of eight patients. 5–7 Additionally, there has been a report of robotically assisted division of vascular rings in chil- dren. 8 There is still, however, a paucity of literature on this subject. We present our case series of VATS di- vision of vascular rings in pediatric patients. Materials and Methods After obtaining Children’s Healthcare of Atlanta In- stitutional Review Board approval, we retrospectively reviewed charts on 13 pediatric patients from February 2002 to September 2004 who underwent VATS divi- sion of their vascular rings. All patients with vascular rings consisting of a double aortic arch or a right arch with an aberrant left subclavian artery and a left liga- mentum arteriosum were considered for VATS divi- sion. Preoperatively, most patients were evaluated Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, New Orleans, LA, February 11–15, 2005. Address correspondence and reprint requests to Dr. Mark L Wulkan, Division of Pediatric Surgery, 2015 Uppergate Drive, Atlanta, GA 30322. 289