Experience of ultrasound diagnostics of vascular rings and its influence on surgical treatment

The term vascular ring (VR) is now used for all congenital anomalies of vessels of the aorta system, which cause compression of the trachea and esophagus. This is an extremely rare pathology and accounts for less than 1% of all CHD. Congenital anomalies of the aortic arch have been known at least since 1735, when Hunauld described an abnormal right subclavian artery, Hommel in 1737 – the double arch of the aorta, Fioratti and Aglietti – the right arch of the aorta in 1763. Correlation of clinical manifestations of swallowing disorders with the presence of an abnormal right subclavian artery was presented to Bayford at a meeting of the Medical Association in London in 1787 and published in 1794. However, there was no significant clinical interest in this group of anomalies until the 1930s, when the use of barium esophagography was introduced. Then there was an opportunity to diagnose some anomalies of the aortic arch during the lifetime, and not only as a result of pathologic-anatomical sections. Then surgical methods of treatment of various anatomical variants of pathology of the aortic arc began to develop. For the first time the term “vascular ring” was used in literature in 1945 by Dr. Robert Gross from Boston Children’s Hospital. He described two classical variants of complete vascular rings – the double artery of the aorta and the right arch of the aorta with the left arterial ligament. Modern interest in these abnormalities was caused by the first surgical correction of the double aortic arch in 1945. Subsequently, he first performed surgical treatment and most other forms of VR. In modern cardiac surgery, the results of VR treatment are excellent and most patients have complete disappearance of symptoms [1, 2]. Despite the fact that modern methods of diagnosing congenital heart defects are accurate, postnatal diagnostics of the VR remains difficult. At present, the best method for diagnosis of VR is CT, which can accurately determine the anatomy of the VR and the associated trachea pathology [3–5]. Echocardiography does not provide such amount of information for the diagnosis of VR as CT. However, this is a safe method, which, while using the necessary projection, still allows you to diagnose VR. Particularly important is the echocardiographic fetus, which allows you to diagnose the VR before the baby is born [6–8]. Objective. The purpose of the study was to analyze the effectiveness of ultrasound diagnosis of VR and its effect on surgical treatment. Materials and methods. From 2004 to 2017, 18589 surgical operations for CHD were performed at our Center (Fig.1). From 2004 to 2017, more than 65,000 echocardiographs of children under the age of 18 were and 7740 primary examinations of pregnant women conducted at our Center. All tests were performed by the method of transthoracic echocardiography and transabdominal fetal echocardiography on ultrasound scanners Philips Sonos 7500, Siemens Acuson Sequoia 512, Philips iU22, Philips iE33, Philips EPIQ 7 with the convection transducer with 9–1 MHz and sector transducers with 12 MHz, 8 MHz, 4–1 MHz operating frequency. Computer tomography (CT) to confirm the ultrasound diagnosis of VR was performed on a 16-slice tomography Siemens Somatom Sensation Results and discussion. From 2007 to 2017 in our Center 95 (0,51%) surgical interventions were performed with the УДК 616.12-007.2-053.2-07:618.33

The term vascular ring (VR) is now used for all congenital anomalies of vessels of the aorta system, which cause compression of the trachea and esophagus. This is an extremely rare pathology and accounts for less than 1% of all CHD. Congenital anomalies of the aortic arch have been known at least since 1735, when Hunauld described an abnormal right subclavian artery, Hommel in 1737 -the double arch of the aorta, Fioratti and Aglietti -the right arch of the aorta in 1763. Correlation of clinical manifestations of swallowing disorders with the presence of an abnormal right subclavian artery was presented to Bayford at a meeting of the Medical Association in London in 1787 and published in 1794. However, there was no significant clinical interest in this group of anomalies until the 1930s, when the use of barium esophagography was introduced. Then there was an opportunity to diagnose some anomalies of the aortic arch during the lifetime, and not only as a result of pathologic-anatomical sections. Then surgical methods of treatment of various anatomical variants of pathology of the aortic arc began to develop. For the first time the term "vascular ring" was used in literature in 1945 by Dr. Robert Gross from Boston Children's Hospital. He described two classical variants of complete vascular rings -the double artery of the aorta and the right arch of the aorta with the left arterial ligament. Modern interest in these abnormalities was caused by the first surgical correction of the double aortic arch in 1945. Subsequently, he first performed surgical treatment and most other forms of VR. In modern cardiac surgery, the results of VR treatment are excellent and most patients have complete disappearance of symptoms [1,2].
Despite the fact that modern methods of diagnosing congenital heart defects are accurate, postnatal diagnostics of the VR remains difficult. At present, the best method for diagnosis of VR is CT, which can accurately determine the anatomy of the VR and the associated trachea pathology [3][4][5].
Echocardiography does not provide such amount of information for the diagnosis of VR as CT. However, this is a safe method, which, while using the necessary projection, still allows you to diagnose VR. Particularly important is the echocardiographic fetus, which allows you to diagnose the VR before the baby is born [6][7][8].
Objective. The purpose of the study was to analyze the effectiveness of ultrasound diagnosis of VR and its effect on surgical treatment.  (Fig. 2).
Since 2011 during the conduction of the fetal echocardiography a new protocol with the necessary views for diagnostics of the VR was made: 1) the 3-vessel and trachea view, 2) the aortic arch long-axis view, 3) the transverse view of the upper abdomen. Thanks to the introduction of the new protocol, the echocardiography of the fetus has been able to significantly improve the prenatal diagnosis of VR. From 2012 to 2017 the growth of the number of prenatally diagnosed VR (Table 1) is recorded [9].
From 2014 to 2017 21 patients with prenatal diagnosis of VR were operated (Fig. 3). In the articles of many authors, the wide introduction of additional methods of VR diagnosis -such as ultrasound diagnostics, MRI and bronchoscopyis used to reduce X-rays. This is especially true for young children [3,5,6]. However, in order to determine the optimal path of surgical treatment, it is necessary to know the anatomy of the VR and the trachea perfectly. At the present stage, only CT allows the image of the artery of the aorta and its vessels and trachea of the required quality [1,4]. Nevertheless, ultrasound diagnosis of VR is a non-invasive, safe diagnostic method that does not require special patient preparation and can be widely used as a screening method for prenatal and postnatal diagnosis of VR.
Conclusions. Surgical treatment of VR has excellent results with low surgical risk. Despite the fact that for the successful surgical treatment of VR is necessary CT to perform for required to clarify the anatomy of the VR and the trachea, prenatal and postnatal ultrasound diagnostics of the VR allows the detection of a group of asymptomatic patients.