Original Article |

Vascular Compression of the Airway:  Establishing a Functional Diagnostic Algorithm

Derek J. Rogers, MD; Mary Beth Cunnane, MD; Christopher J. Hartnick, MD, MS Epi
JAMA Otolaryngol Head Neck Surg. 2013;139(6):586-591. doi:10.1001/jamaoto.2013.3214.
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Importance Pediatric imaging carries the risk of radiation exposure. Children frequently undergo computed tomography with angiography (CTA) for findings on bronchoscopy with limited knowledge regarding the necessity of such imaging.

Objective To report our experience with all pediatric patients at our institution over an 8-year period with airway symptoms warranting bronchoscopy followed by CTA for potential vascular anomaly. Goals were to report the percentage of positive findings seen on CTA leading to surgery; discuss relative radiation exposure risk and sedation risk for additional radiologic studies; and propose a functional diagnostic algorithm.

Design, Setting, and Participants Retrospective chart review of 42 children aged 2 months to 11 years with tracheomalacia who underwent CTA between 2004 and 2012 in our tertiary aerodigestive center.

Interventions Bronchoscopy and CTA.

Main Outcomes and Measures Presence of vascular anomaly and need for thoracic surgery.

Results Of these 42 children, 21 (50%) had a vascular anomaly identified on CTA. Of these 21, 17 (81%) had innominate artery compression; 1 (5%) had double aortic arch; 1 (5%) had right aortic arch; 3 (14%) had bronchial compression by pulmonary artery; and 1 (5%) had dextrocardia with duplicated vena cava. Six (29%) of these 21 had clinical symptoms and CTA findings requiring thoracic surgery. The most common symptoms in children requiring thoracic surgery were cough, cyanosis, and stridor.

Conclusions and Relevance Deciding when to obtain imaging for bronchoscopic findings suggestive of vascular compression remains challenging. A diagnostic algorithm is proposed as a means to provide the best clinical care while weighing risks of additional radiation exposure vs sedation and exposure to general anesthesia.

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Figure 1. Illustration of potential bronchoscopic findings secondary to vascular anomalies, reprinted with permission.1 LMB indicates left main bronchus; RBI, right bronchus intermedius; RMB, right main bronchus.

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Figure 2. Complete anterior mid-tracheal compression due to innominate artery.

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Figure 3. Right anterior and posterior distal tracheal compression due to double aortic arch.

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Figure 4. Diagnostic algorithm for a child with possible vascular anomaly. Short-segment compression is defined as 33% or less of the tracheal length; long-segment compression, more than 33% of the tracheal length. CTA indicates computed tomography with angiography of the neck and chest; DLB, direct laryngoscopy with bronchoscopy; GERD, gastroesophageal reflux disorder; and MRI, magnetic resonance imaging.




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