Vascular Malformations

Vascular surgery is the specialized field of medicine that focuses on the surgical management of the pathologies of the peripheral circulation. The main goal of most vascular procedures is to restore circulatory function to the affected vessels by relieving occlusions or by redirecting blood flow (e.g., bypass). Surgical intervention is either open or endovascular. Vascular interventions require a multidisciplinary approach, including vascular surgeons, interventional radiologists, anesthesiologists (or anesthetists), nurses, physiotherapists, and occupational therapists.

The branchial arches, also known as pharyngeal or visceral arches, are embryonic structures seen in the development of vertebrates that serve as precursors for many structures of the face, neck, and head. These arches are composed of a central core of mesoderm, which is covered externally by ectoderm and internally by endoderm. Indentations between arches are known as the pharyngeal clefts, or grooves, externally and the pharyngeal pouches internally. Each pharyngeal arch contains cartilage and muscular components, which are supplied by a cranial nerve (derived from neural crest cells), and an artery, known as a pharyngeal aortic arch. Some of these aortic arches go on to form the great vessels near the heart.

Vascular rings are a group of rare malformations featuring congenital abnormalities of the aortic arch. The aberrant arteries often form a ring around the esophagus and trachea, putting pressure on these structures. Clinical symptoms range from stridor, respiratory distress, and/or dysphagia in neonates, to asymptomatic forms, noted incidentally in adults. Diagnosis is confirmed through X-ray and echocardiography, but may be further defined with a computed tomographic (CT) scan. Definitive treatment is surgical, and the prognosis is excellent as clinical recovery is immediate.

Coarctation of the aorta is a narrowing of the aorta between the aortic arch and the iliac bifurcation commonly around the point of insertion of the ductus arteriosus. Coarctation of the aorta is typically congenital and the clinical presentation depends on the age of the patient. Neonates present with heart failure upon the closure of the ductus arteriosus, while children and adults present with hypoperfusion and/or hypertension. Classic findings on physical exam include radio-/brachio-femoral delay and decreased blood pressure in the lower limbs. Diagnosis is confirmed by echocardiogram. Patients should be surgically managed as early as possible to avoid complications of hypertension. Close follow-up is required as the risk of hypertension and re-coarctation remain.