Medical Image of the Month: Double Aortic Arch

Figure 1. A chest radiograph performed after endotracheal intubation of the patient demonstrated prominence of the upper mediastinum in the region of the right paratracheal strip (red arrow).

Figure 2. A non-contrasted CT of the chest demonstrates a complete vascular ring secondary to the patient’s double aortic arch (outlined in red) surrounding the trachea (T) and esophagus (E).

Case Presentation: A 78-year-old gentleman presented to the hospital via EMS with altered mental status. An urgent CT of the head performed in the emergency room demonstrated a large, right intraparenchymal hemorrhage with intraventricular extension into the right lateral ventricle. His Glascow Coma Scale score was 6, and he was intubated for airway protection.  A chest radiograph performed to verify placement of the endotracheal tube demonstrated prominence of the upper mediastinum in the region of the right paratracheal strip (Figure 1). A CT of the chest (Figure 2) demonstrated a double aortic arch corresponding to the upper mediastinal abnormality noted on the chest radiograph. In speaking with the patient’s family after acquiring the CT of the chest, they stated that the patient had long-term issues with dysphagia – specifically choking with solid foods. Unfortunately, the patient passed away from complications of his large intraparenchymal hemorrhage.

A double aortic arch results from persistence of both the right and left embryonic arches with each arch giving rise to the ipsilateral, separate carotid and subclavian arteries (1). A double aortic arch is the most common cause of a symptomatic vascular ring with the trachea and esophagus being compressed by the two arches (1). Symptoms usually arise in childhood with good outcomes with surgical repair of this abnormality in pediatric populations. A few case series exist describing repair of this anomaly in adult populations (2).

Kelly Wickstrom DO, Steven P. Sears DO, and Laura Meinke MD

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Hanneman K, Newman B, Chan F. Congenital variants and anomalies of the aortic arch. Radiographics. 2017 Jan-Feb;37(1):32-51. [CrossRef] [PubMed]
2. Noguchi K, Hori D, Nomura Y, Tanaka H. Double aortic arch in an adult. Interact Cardiovasc Thorac Surg. 2012 Jun;14(6):900-2. [CrossRef] [PubMed]

Cite as: Wickstrom K, Sears SP, Meinke L. Medical image of the month: Double aortic arch. Southwest J Pulm Crit Care. 2019;18(5):120-1. doi: https://doi.org/10.13175/swjpcc019-19 PDF 

Medical Image of the Week: Aortic Ring

Figure 1. Post-intubation chest radiograph showing a widened right paratracheal stripe (arrow).

A 78 year old man presented with altered mental status and was found to have an intraventricular hemorrhage. He was intubated for airway protection. On the post-intubation chest radiograph (Figure 1), the patient was noted to have a widening of the right paratracheal stripe.

A CT chest (Figure 2) was obtained to characterize this finding and revealed an aortic ring which encircles the trachea and esophagus.

Figure 2. Axial (Panel A) and coronal (Panel B) of thoracic CT soft tissue windows showing the aortic ring.

Vascular rings are uncommon congenital abnormalities, accounting for approximately 1% of congenital heart disease. Complete vascular rings can occur with a right aortic arch with a ligamentum arteriosum or with a double aortic arch, such as with our patient (1). This ring can cause airway compression, stridor, esophageal compression, or no symptoms at all. As the embryo develops, the left fourth pharyngeal arch normally persists to become the aortic arch while the right fourth pharyngeal arch regresses. If both fourth pharyngeal arches persist, a right aortic arch can form and surround the trachea and esophagus (2).

Candy Wong MD¹, Tammer Elaini MD², Soyoung Park MD², Scott Rosen MD², and Sai Parthasarathy MD¹

¹Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine. Department of Medicine

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Turner A, Gavel G, Coutts J. Vascular rings-presentation, investigation and outcome. Eur J Pediatr. 2005;164(5):266-70. [CrossRef] [PubMed]
2. Vatish J, McCarthy R, Perris R. A double aortic arch presenting in the 7^th decade of life. J Surg Case Rep. 2013.(10):pii:rjt081. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Park S, Rosen S, Parthasarathy S. Medical image of the week: aortic ring. Southwest J Pulm Crit Care. 2014;9(4):121-2. doi: http://dx.doi.org/10.13175/swjpcc130-14 PDF