A right-sided aortic arch with an isolated left subclavian artery represents a rare anatomical variant, posing diagnostic challenges and clinical complexities. Here, we present a case of a 14-year-old male presenting with respiratory symptoms, unveiling a right-sided aortic arch with an isolated left subclavian artery. Through detailed clinical evaluation, radiographic imaging, and diagnostic modalities including chest radiography, computed tomography angiography, ultrasound, and time-of-flight magnetic resonance angiography, the anatomical features and associated complications were delineated. The discussion encompasses embryological underpinnings, clinical manifestations, and therapeutic considerations, shedding light on the rarity and clinical implications of this anomaly.

UNASSIGNED: Perioperative anesthetic management in cases of severe airway obstruction with positional symptoms can be associated with difficulties in ventilation or intubation, with a risk of acute respiratory decompensation at every stage of anesthesia.
METHODS: Here we describe the anesthetic management of an 18-year-old woman with a mature teratoma who presented with progressive exertional dyspnea that was aggravated in the supine position in the operating room. After tracheal intubation, the tidal volume decreased, airway pressure increased, and pet CO2 grew beyond 105 mmHg without oxygen desaturation, prompting a femoro-femoral cardio-pulmonary bypass.
UNASSIGNED: Cardio-pulmonary bypass (CPB) can facilitate tumor dissection by safely deflating the lungs and retracting the heart, enhancing exposure and reducing risks of hemodynamic or respiratory complications. However, systemic heparinization may increase complications, necessitating a preoperative risk assessment.
CONCLUSIONS: Preoperative management of large mediastinal masses requires careful attention to tumor anatomical details and relationships with surrounding structures. Preoperative preparation includes multimodality imaging and multidisciplinary team discussions to assess MMS risk, requiring specialized center management.

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UNASSIGNED: Left pulmonary artery sling is an uncommon condition observed in infants. The severity of the condition is determined by the compression of the broncho-tracheal tree induced by the ring sling compression. The main goal of the treatment is to adjust the left pulmonary artery and eventually relieving the compression through surgery. The long-term outcome associated with the complexity of the anomalies.
METHODS: A nine-months old patient complained of worsening respiratory distress. The computed tomography scan revealed the potential presence of a left pulmonary artery sling and compression of the trachea, without any abnormalities in the trachea itself. Echocardiography study showed no intracardiac lesion. We successfully did left pulmonary artery transection and re-implantation to main pulmonary artery without cardiopulmonary bypass.
UNASSIGNED: Pulmonary artery sling commonly treated with reimplantation of the sling to its origin that usually required cardiopulmonary bypass machine. However, in our case we delivered it without the need of cardiopulmonary bypass. The outcome result turned excellent with echo post-operative showed confluent pulmonary arteries.
CONCLUSIONS: The optimal approach to treating congenital pulmonary artery sling is through early surgical intervention in symptomatic patients. Following surgical repair devoid of tracheal lesion, the prognosis appears favorable, and routine follow-up is required to determine the long-term effects.

Airway obstruction requires urgent intervention. When dealing with the right brachiocephalic artery mycotic pseudoaneurysms, the risk of rupture and massive hemorrhage adds greater urgency to the management. Furthermore, tracheal compression presents difficulties during airway management. This report highlights the airway and anesthetic challenges encountered during the procedure and emphasizes the importance of tailored intervention for optimal patient care. We describe the clinical case of a 38-year-old male patient who presented with a large recurrent right brachiocephalic artery pseudoaneurysm associated with tracheal compression. The patient required urgent surgical intervention due to the pseudoaneurysm\'s enlargement and progressive respiratory distress. Awake fiber-optic intubation was not feasible. A cardiopulmonary bypass was kept on standby in the event of failed intubation and ventilation, or circulatory collapse. Endotracheal intubation was performed successfully using a video-laryngoscopy. After successful surgical repair of the pseudoaneurysm, the patient was transferred to ICU where he was extubated 48 hours post-surgery, following treatment with methylprednisolone for edematous aryepiglottic folds identified during video-laryngoscopy. Overall, this case emphasizes the importance of early diagnosis, prompt surgical intervention, and effective teamwork in managing rare and potentially life-threatening conditions like mycotic pseudoaneurysms. It also highlights the critical role of anesthesiologists in providing optimal perioperative care, ensuring hemodynamic stability, managing airway challenges, and facilitating successful surgical outcomes. In our work, we also provide a summary of the reported similar cases.

BACKGROUND: Mediastinal tumors pose a challenging respiratory and circulatory management during anesthesia procedures, there is a risk of circulatory collapse or complete airway obstruction, which in severe cases can lead to cardiac arrest. We reported a case of anesthetic management using a bronchial blocker placed outside the tracheal tube. In this case report, the patient\'s trachea was so severely compressed that the airway was extremely narrow, only 4 mm at its narrowest point. By reporting the anesthetic management of this patient, we intend to provide an unusual approach for airway management.
METHODS: A 52-year-old male patient was admitted to the hospital due to cough and expectoration for one year. Additionally, the patient experienced chest tightness and asthma after physical activity. The enhanced computed tomography revealed there existed an irregular soft tissue mass in the right upper mediastinum, which significantly compressed the trachea and esophagus. The results of the mediastinal puncture pathology showed the presence of mesenchymal tumors. According to the results above, the patient was diagnosed with a mediastinal tumor and scheduled to undergo tumor resection under general anesthesia. We used a bronchial occluder outside the tracheal tube for general anesthesia. After surgery, the patient received thorough treatment and was subsequently discharged from the hospital.
CONCLUSIONS: In patients with severe airway compression from a mediastinal tumor airway compression, positioning a bronchial occluder externally to the tracheal tube is an effective method of airway management. However, we still need more clinical practice to help the process become more standardized.

Achalasia is one of the most common esophageal motility disorders. Typical symptoms include dysphagia, food regurgitation, respiratory symptoms, chest pain, and weight loss. Respiratory obstruction due to tracheal compression by the massively dilated esophagus is a very rare but fatal complication. A 36-year-old male presented with progressive respiratory distress with a history of untreated dysphagia and regurgitation. Further diagnosis revealed dilatation of the esophagus with undigested food. A Heller myotomy with fundoplication was performed and respiratory symptoms were relieved. Tracheal compression and acute airway obstruction caused by esophageal dilatation in achalasia is a rare presentation. Early recognition of this rare manifestation is critical and emergency treatment is necessary for life saving. Radiological examination can help physicians find the dilated esophagus. Respiratory symptoms resulting from tracheal compression by a dilated esophagus rarely occurred. Even though physicians should be alert and early decompression has to be performed immediately.

UNASSIGNED: Lymphatic malformation (LM), most commonly present in the neck area, is benign vascular malformations of the lymphatic system. In an infant, however, LM poses a high risk of adverse outcomes.
UNASSIGNED: We present a case with a giant fetal LM. Through ultrasonography, at 23+ weeks of gestation, a septate cystic mass 7.2×6.5×6.3 cm in size was found on the right side of the fetus\'s neck. After extensive counseling by the multidisciplinary team, the parents chose to continue the pregnancy. Severe fetal tracheal compression was observed at 29 weeks by magnetic resonance imaging (MRI). At 31 weeks and 5 days, owing to suspected fetal distress, an emergency cesarean section was performed and a male baby weighing 1720 g was delivered. The mass was 10×16×8 cm in size and ex utero intrapartum treatment (EXIT) was implemented. Due to progressive growth of the mass secondary to intralesional bleeding, an intralesional injection of bleomycin was administered three days later. This injection was repeated at the age of 1 month and 8 days. The baby was followed up and, by a year after his birth, LM had disappeared. The baby has since been in good health.
UNASSIGNED: Accurate prenatal diagnosis and regular monitoring of a fetus with LM may improve prognosis. It is essential to have a trained multidisciplinary team to evaluate the condition of the fetus and the neonate and to provide treatment based on the evaluation. Our experience with intralesional bleomycin injection for the treatment of a giant fetal neck LM in a preterm infant had a favorable outcome. Long-term follow-up by a multidisciplinary team is needed in such cases.

We present the clinical course and echocardiographic and genetic findings of two fetuses with an unusual vascular ring, created by a left aortic arch with a right arterial duct and an aberrant right subclavian artery. One fetus was diagnosed with 22q11.2 microdeletion and the other became symptomatic in infancy. It is important to consider the position of the arterial ductal ligament in patients who present with tracheoesophageal compressive symptoms in the presence of a left aortic arch. These cases also highlight that a vascular ring formed from a left arch may have similar associations to a vascular ring formed by a right aortic arch.

BACKGROUND: Tracheal compression (TC) due to vascular anomalies is an uncommon, but potentially serious cause of chronic respiratory disease in childhood. Vascular slings are congenital malformations resulting from abnormal development of the great vessels; in this group of disorders the most prevalent entity is the aberrant innominate artery (AIA). Here we provide a report on diagnosis and treatment of AIA in nine children with unexplained chronic respiratory symptoms. We describe the cases, perform a literature review, and provide a discussion on the diagnostic workup and treatment that can help manage AIA.
METHODS: Clinical history, diagnostic procedures and treatment before and after the AIA diagnosis were retrospectively reviewed in nine children (5 boys and 4 girls), who were referred for recurrent-to-chronic respiratory manifestations over 10 years (2012-2022). We performed a comprehensive report on the ongoing clinical course and treatment as well as an electronic literature search on the topic.
RESULTS: Diagnoses at referral, before AIA was identified, were chronic dry barking cough associated with recurrent pneumonia (n = 8, 89%), lobar/segmental atelectasis (n = 3, 33%), atopic/non atopic asthma (n = 3, 33%); pneumomediastinum with subcutaneous emphysema complicated the clinical course in one case. When referred to our Unit, all patients had been previously treated with repeated antibiotic courses (n = 9, 100%), alone (n = 6, 67%) or combined with prolonged antiasthma medications (n = 3, 33%) and/or daily chest physiotherapy (n = 2, 22%), but reported only partial clinical benefit. Median ages at symptom onset and at AIA diagnosis were 1.5 [0.08-13] and 6 [4-14] years, respectively, with a relevant delay in the definitive diagnosis (4.5 years). Tracheal stenosis at computed tomography (CT) was ≥ 51% in 4/9 cases and ≤ 50% in the remaining 5 subjects. Airway endoscopy was performed in 4 cases with CT evidence of tracheal stenosis ≥ 51% and confirmed CT findings. In these 4 cases, the decision of surgery was made based on endoscopy and CT findings combined with persistence of clinical symptoms despite medical treatment. The remaining 5 children were managed conservatively.
CONCLUSIONS: TC caused by AIA may be responsible for unexplained chronic respiratory disease in childhood. Early diagnosis of AIA can decrease the use of expensive investigations or unsuccessful treatments, reduce disease morbidity, and accelerate the path toward a proper treatment.