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Five cardio-thoracic vascular anomalies were detected in a German breed and signalment made the referring
veterinarian suspicious of a vascular ring
shepherd puppy. The patent ductus arteriosus (PDA) was detected anomaly. On physical examination, the
on physical examination (5/6 continuous murmur) and confirmed by dog was small for its age with a thin body
echocardiogram. The persistent right aortic arch (PRAA) was
suspected by the signalment and history of the patient, and
confirmed by survey thoracic radiographs (leftward deviation of the
trachea cranial to the heart on the ventrodorsal projection). The
ventrally deviated trachea cranial to the heart on the right lateral
thoracic radiograph was suggestive of a persistent retroesophageal
left subclavian artery and confirmed at surgery. The persistent left
cranial vena cava and the left azygous vein were detected at surgery.
This case report gives a thorough description of the clinical signs,
diagnostics and treatments required for the detection and
successful resolution of PRAA. The report describes the importance
of having experienced surgeons who can recognize vascular
anomalies associated with PRAA in order to successfully alleviate
the arch and the coinciding oesophageal stricture without
compromising vital blood supplies.
K. J. CHRISTIANSEN, D. SNYDER,
J. W. BUCHANAN AND D. E. HOLT
Journal of Small Animal Practice (2007)
48, 3235
DOI: 10.1111/j.1748-5827.2006.00105.x
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INTRODUCTION
Persistent right aortic arch (PRAA) is the
most common vascular ring anomaly in
dogs (Buchanan 1999). Variations of vascular ring anomalies have been reported
and proven to be quite challenging for surgeons to recognise and correct (Hurley and
others 1993, Holt and others 2000).
To the authors knowledge, this is the
first report documenting the five vascular
anomalies described here in one dog.
CASE HISTORY
A three-month-old, female German shepherd puppy weighing 40 kg was examined
by a referring veterinarian for a one-month
history of regurgitation. The history,
Journal of Small Animal Practice
condition score (2/5). A grade 5/6 continuous murmur was easily audible on cardiac
auscultation. The tentative diagnosis of
patent ductus arteriosus (PDA) was confirmed by echocardiography performed
by a veterinarian with a practice limited
to cardiology. A concurrent vascular ring
anomaly was suspected based on evaluation of plain lateral and dorsoventral
thoracic radiographs. The dog was subsequently fed a mixture of canned foods
and evaporated milk, with instructions
to serve the food in an elevated fashion,
and was referred to the Mathew J. Ryan
Veterinary Hospital at the University of
Pennsylvania (MJR-VHUP), for further
evaluation and treatment.
On initial examination at the MJRVHUP, the now four-month-old puppy
was thin (77 kg) but bright, alert and
energetic. The dog had a grade 5/6 continuous murmur with bounding femoral
pulses. The owner reported that the dogs
regurgitation had decreased significantly
since feeding it only soft food and evaporated milk but that the dog did occasionally regurgitate. The heart rate was 140
bpm and the respiratory rate was 32
breaths/minute, with no evidence of abnormal respiratory sounds. The temperature was 387C. All other systems were
within normal limits. Laboratory abnormalities included mildly low red cell
indices, probably acceptable for the puppys age: haematocrit (34 per cent reference range 403 to 603 per cent), red
blood cell (531106/ll, reference range
583 to 887106/ll), haemoglobin
(117 g/dl, reference range 133 to 205
g/dl) and mean cell haemoglobin (220
pg, reference range 225 to 269 pg).
Serum chemistry abnormalities included
low creatinine (06 mg/dl, reference range
07 to 18 mg/dl), elevated phosphorus
(81mg/dl,referencerange28to61mg/dl),
low total protein (52 g/dl, reference range
54 to 71 g/dl), low total bilirubin (02
mg/dl, reference range 03 to 09 mg/dl)
low anion gap (60 mmol/l, reference range
80 to 210 mmol/l) and low magnesium
(15mg/dl,referencerange16to25mg/dl).
Cardiac evaluation included a six-lead
electrocardiogram (ECG), repeated thoracic radiographs and echocardiography.
The ECG showed a normal sinus arrhythmia with intermittent, infrequent monomorphic atrial premature complexes.
The lateral thoracic radiograph revealed
an enlarged cardiac silhouette, a widened
cranial mediastinum and a soft tissue
opacity cranial to the heart compatible
with the appearance of a dilated cranial
thoracic oesophagus. The trachea was ventrally displaced at the same level, and the
caudal pulmonary vessels were prominent
(Fig 1). The exaggerated ventral deviation
of the trachea on the lateral view was
highly suggestive of a left retroesophageal
subclavian artery (Buchanan 2004). A
leftward deviation of the trachea just cranial to the heart on the ventrodorsal radiograph was highly suggestive of a PRAA
(Fig 2; Buchanan 2004). Echocardiography confirmed the presence of a PDA with
left to right flow. Moderate left atrial and
left ventricular dilation and mild mitral
regurgitation were also apparent. The
findings were discussed with the owner
and the dog was scheduled for surgery
the following week. Repeat thoracic
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DISCUSSION
To date, only two studies have been published on the long-term results of surgical
correction of PRAA in dogs. One hundred
and ninety-one radiographically confirmed
cases of PRAA between 1966 and 1976
were evaluated in one study. The authors
concluded that immediate postoperative
survival was good but long-term prognosis
was poor as dogs continued to suffer from
regurgitation and bouts of aspiration pneumonia (Shires and Liu 1981). Twenty-five
cases of surgically corrected PRAA patients
from 1980 to 1995 were evaluated in a second study. The authors concluded that 23
(92 per cent) of the 25 dogs had complete
alleviation of clinical signs. The remaining
two dogs (8 per cent) showed improvement
in signs and regurgitated less than once
per week (Muldoon and others 1997).
In the current study, postoperative persistence of the megaoesophagus and regurgitation in early postoperative periods did
not indicate a poor long-term survival
(Muldoon and others 1997). The reason
for the disparity in results between these
two studies is not clear.
At surgery, identification and correction
of all vascular anomalies are vital to resolve
oesophageal obstruction. Ligation, transfixation and transection of the retroesophageal left subclavian artery facilitated
exposure and dissection of the PDA. Following transection of the left subclavian
artery, blood to the left forelimb is supplied
from the left vertebral artery which enters
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