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\begin{document}

\title{Impact on the trachea in children with prenatally diagnosed vascular
ring formed by a right aortic arch}



\author[1]{Christopher Oakley}%
\author[1]{Alice Hurn}%
\author[1]{Claire Suckling}%
\author[1]{Grace Moriarty}%
\author[1]{john simpson}%
\author[1]{Simona Turcu}%
\author[1]{Jane Heraghty}%
\author[1]{Vita Zidere}%
\author[1]{Andrew Nyman}%
\author[1]{Trisha Vigneswaran V}%
\affil[1]{Evelina London Children's Hospital}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objective:} There has been a rise in the prenatal detection of
right sided aortic arch (RAA). When associated with a left-sided
arterial duct (LD), this forms a vascular ring encircling the trachea.
Infants may have symptoms or signs suggestive of trache-oesophageal
compression but many are asymptomatic. The objective of this study was
to investigate the relationship between symptoms and severity of
tracheo-bronchial compression assessed by bronchoscopy.
\textbf{Methods:} Retrospective review of all cases of prenatally
diagnosed RAA-LD in the absence of associated congenital heart disease
at Evelina London Children's Hospital and Kings College Hospital over a
4-year period between April 2015-2019. Clinical records, fetal
echocardiograms and free-breathing flexible bronchoscopy (FB) data were
reviewed. \textbf{Results:} 112 cases of isolated RAA-LD were identified
of whom 82 cases (73\%) underwent FB. FB was performed median age of 11
months (range 1-36 months), no complications occurred. Aberrant left
subclavian artery (ALSA) was present in 86\% (96/112) and mirror image
branching (MIB) in 13\% (15/112). 34/112 (30\%) reported symptoms during
follow up. 36/77 (47\%) with ALSA who underwent FB showed
moderate-severe compression mostly at distal tracheal and carinal level
of whom 38\% had parent-reported symptoms. Moderate-severe compression
was seen in 3/5 (60\%) with MIB mostly at mid tracheal level of whom 3
were symptomatic but only 2 with compression. In total 36\% (18/50) of
investigated asymptomatic patients showed moderate to severe
compression. Respiratory symptoms were poorly predictive of
moderate-severe compression (positive predictive value 66\%).
\textbf{Conclusion:} The absence of symptoms did not exclude significant
tracheal compression. The anatomical effect of the vascular ring is
underappreciated when symptoms alone are used as a marker of tracheal
compression.%
\end{abstract}%



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\includegraphics[width=0.70\columnwidth]{figures/Figure-2---RAA-bronchoscopy-diagram/Figure-2---RAA-bronchoscopy-diagram}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-3---RAA-bronchoscopy-diagram/Figure-3---RAA-bronchoscopy-diagram}

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\textbf{Hosted file}

\verb`Table 1- Findings in children with RAA-LD undergoing bronchoscopy.docx`  available at \url{https://authorea.com/users/525552/articles/595895-impact-on-the-trachea-in-children-with-prenatally-diagnosed-vascular-ring-formed-by-a-right-aortic-arch}

\textbf{Hosted file}

\verb`Table 2- 2 x 2 table demonstrating predictive value of symptoms for tracheal compression. .docx`  available at \url{https://authorea.com/users/525552/articles/595895-impact-on-the-trachea-in-children-with-prenatally-diagnosed-vascular-ring-formed-by-a-right-aortic-arch}

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