Arterial Malformations which Cause Compression of the Trachea or Esophagus

In recent years observations have shown that there are certain arterial malformations in the superior mediastinum which bring about significant compression of either the trachea or esophagus, or both of these structures. If the arterial derangements are of such a nature that symptoms are produced by obstruction of the esophagus and particularly by the impairment of the tracheal airway, it is of prime importance to recognize the underlying vascular malformation because surgical approach to the problem has a great deal to offer either by division of an offending vessel or by displacement of an artery in such a manner that more room is provided for the esophagus and trachea. Roentgenographic examination of the esophagus and trachea with contrast media usually gives a fairly clear impression of the arterial derangement and leads to accurate diagnosis. Visualization of the aortic pathways by angiocardiography or by retrograde aortography is seldom necessary. At operation, all these anomalies can be exposed through a left anterolateral transpleural approach to the superior mediastinum. Most of the thymus gland can be dissected off and discarded, allowing good visualization of the region. Emphasis must be placed upon the fact that constrictions of the esophagus or trachea are not caused solely by vessels or ligaments, but that constriction is likewise produced by fibrous bands or sheaths which accompany these vessels and ligaments. Hence, it is important, not only to divide or displace the appropriate vessel or ligament, but also to cut any strands or bands of tissue which accompany these structures and which form a part of a constricting mechanism. In a series of cases in which surgical therapy has been undertaken for alleviating compression of the esophagus or trachea for the various vascular anomalies under consideration, it has been shown that the risks of surgery can be kept relatively low and that the benefits which accrue from such treatment are real and well worth seeking.