Introduction
Accurate diagnosis of Aortic arch (AoA) anatomy is critical in the care
of patients with congenital heart disease for planning cardiac
surgery/intervention, diagnosing associated congenital heart defects
(CHD), and evaluating possible compression of the esophagus or
airway.1 Arch sidedness has been shown to influence
the surgical incision, cardiopulmonary bypass cannulation, and
interventional approach.2,3 Arch anomalies can
increase the technical difficulty of endovascular treatment including
carotid stent procedures and the risk of neurologic complications, and
correct identification of arch anomalies helps avoid potential
complications.4,5 Notably, patients with right aortic
arch and mirror image branching have been reported to have additional
CHD in up to 98% of cases.6
Determination of AoA sidedness is traditionally completed with
echocardiography as being contralateral to the direction of the first
brachiocephalic artery in suprasternal view.7 However,
this method is challenged by poor acoustic windows, and can be
technically difficult in small neonates for whom neck extension may not
be feasible, the critically ill, or patients with aberrant subclavian
artery. This method may also miss a double aortic arch (DAA). Given
these challenges, the need for additional advanced imaging with CT or
MRI for diagnosis has been reported in up to 28% of patients with AoA
anomalies.8
In fetal echocardiography, imaging of the trachea is used routinely in
the 3-vessel trachea view as a part of standard protocols to determine
AoA sidedness and evaluate for AoA anomalies or pulmonary artery (PA)
sling.9,10 In pediatric or adult echocardiography,
however, tracheal imaging is not routine. Despite this, the tracheal
rings can be identified with transthoracic echocardiography by the
classic echogenic shadow they produce. While imaging the trachea in
echocardiography is not novel, we have found no published literature
about its use or feasibility. The objective of this study was to
evaluate the feasibility of imaging the trachea with echocardiography
and bring attention to this often-forgotten technique. We hypothesize
that visualization of the trachea with echocardiography can be
accomplished in most pediatric patients, and that the technique of a
tracheal sweep can identify AoA sidedness or double aortic arch.