Methodology of echocardiographic analysis of morphological variations of the aortic arch and its branches in children – own experience

Abstract

We wish to share our experience in echocardiographic assessment of the course of the aortic arch, illustrating it with multiple examples of the majority of possible variants. The course of the aortic arch and its branches may be visualized using high parasternal and suprasternal views in sagittal and transverse planes. It is hardly ever possible to visualize the entire aortic arch on a single ultrasonographic section, particularly in the case of pathological variations. Echocardiography should be performed in a dynamic mode, as in the case of CT angiography or magnetic resonance, by gradually moving the ultrasound beam and following the position of subsequent aortic segments and branches on the screen. Due to disturbances in ultrasound propagation caused by air-containing tissues, such as the trachea, bronchi and lungs as well as bones (sternum and ribs), each evaluation of the entire arch requires the use of a higher number of echocardiographic views. The presented data show that echocardiographic detection of the main details of aortic arch anomalies is possible in practically all cases. In the case of patients considered for surgical treatment, all unresolved issues should be clarified with CT angiography or MRI, enabling 3 dimensional reconstruction of vessels and other thoracic structures. Knowledge of the main elements of an abnormal arch is crucial for proper planning of this type of examination; therefore the diagnostic process should be always initiated with echocardiography. Echocardiography is often sufficient to answer all clinical questions and finalize the diagnostic process.

Role of Transthoracic Echocardiography in the Diagnosis of Double Aortic Arch

“…[1][2][3][4] Double aortic arch, the most frequent type of vascular ring, [4][5][6][7] is caused by an embryogenic anomaly with persistent right and left fourth embryonic aortic arches. 4,8,9 These two patent arches resulted in a bifurcated ascending aorta, whose branches encircle the trachea and esophagus and posteriorly join to form a single descending aorta, forming a ring around these structures that can cause compression. 1,2,4,8 The right arch is often dominant (75%), with only 5% of cases presenting both arches of equal size as in the case reported here.…”

“…4,8,9 These two patent arches resulted in a bifurcated ascending aorta, whose branches encircle the trachea and esophagus and posteriorly join to form a single descending aorta, forming a ring around these structures that can cause compression. 1,2,4,8 The right arch is often dominant (75%), with only 5% of cases presenting both arches of equal size as in the case reported here. 2,4 In most cases, double aortic arch occurs as an isolated lesion, although it may be associated with other malformations such as tetralogy of Fallot, truncus arteriosus, and transposition of the great arteries.…”

“…4,6 In cases of significant tracheal and esophageal compression, symptoms such as stridor, dyspnea, respiratory failure, and feeding difficulties may be observed soon after birth. 1,3,4,6,8,9 On the other hand, if compression is minimal, the vascular ring will be accidentally diagnosed in asymptomatic adults. 3,6,8,9 Treatment is reserved for symptomatic cases and consists of surgical resection of one of the aortic arches, preferably the smaller one.…”

“…1,3,4,6,8,9 On the other hand, if compression is minimal, the vascular ring will be accidentally diagnosed in asymptomatic adults. 3,6,8,9 Treatment is reserved for symptomatic cases and consists of surgical resection of one of the aortic arches, preferably the smaller one. [2][3][4]6,9 However, after tracheal compression release, respiratory symptoms may persist in a significant number of children (54%) due to tracheomalacia, as in the case described in this report.…”

“…Furthermore, it has the advantages of low cost and not requiring the use of contrast, sedation, or radiation. 1,3,4,[6][7][8][9] This report presents a systematic approach to diagnosing double aortic arch through transthoracic echocardiography, focusing on its presentation pattern in the different echocardiographic windows. A careful assessment of the aortic arch with determination of its laterality and the branching pattern of brachiocephalic vessels is essential for identifying a double aortic arch by echocardiographic examination.…”