CASE REPORT

Multiple vascular anomalies

in a regurgitating German
shepherd puppy


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

Department of Clinical Studies, University of

Pennsylvania School of Veterinary Medicine,
Philadelphia, PA 19104-6010, USA

32

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 4
0 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 (7
7 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 38
7C. 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 40
3 to 60
3 per cent), red
blood cell (5
31106/ll, reference range
5
83 to 8
87106/ll), haemoglobin
(11
7 g/dl, reference range 13
3 to 20
5
g/dl) and mean cell haemoglobin (22
0
pg, reference range 22
5 to 26
9 pg).
Serum chemistry abnormalities included
low creatinine (0
6 mg/dl, reference range
0
7 to 1
8 mg/dl), elevated phosphorus

Vol 48
January 2007
2006 British Small Animal Veterinary Association

Multiple vascular anomalies in a German shepherd puppy

(8
1mg/dl,referencerange2
8to6
1mg/dl),
low total protein (5
2 g/dl, reference range
5
4 to 7
1 g/dl), low total bilirubin (0
2
mg/dl, reference range 0
3 to 0
9 mg/dl)
low anion gap (6
0 mmol/l, reference range
8
0 to 21
0 mmol/l) and low magnesium
(1
5mg/dl,referencerange1
6to2
5mg/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

radiographs immediately before surgery

revealed no evidence of aspiration pneumonia. The dog was blood typed dog
erythrocyte antigen (DEA) 1.1 negative.
A coagulation screen was within the normal limits.
The dog was premedicated with 0
01
mg/kg glycopyrolate (Robinul; Fort
Dodge), 0
25 mg/kg hydromorphone
(Dilaudid; Abbott) and 0
25 mg/kg
midazolam (Versed; Roche). General anaesthesia was induced with 2
5 mg/kg propofol
(PropoFlo; Schering Plough), 0
12 mg
hydromorphone (Dilaudid; Abbott) and
0
12 mg midazolam (Versed; Roche),
delivered through a 20 G cephalic vein
catheter. Anaesthesia was maintained with
a 1
0 lg/kg/minute fentanyl (Taylor)
infusion, intermittent intravenous injections of 1
0 mg/kg etomidate (Amidate;
Hospira) and isoflurane delivered in 100
per cent oxygen. An additional catheter
was placed in the saphenous vein, and
a double lumen catheter was placed in
the left jugular vein. A 22 G catheter
was placed in the right dorsal pedal artery.
The jugular vein and dorsal pedal artery
catheters were connected to a transducer
to record central venous and direct arterial
pressures, respectively. The left thorax was
clipped and prepared for aseptic surgery.
A left fourth intercostal space thoracotomy was performed. Before incising the
intercostal muscles, the area around the
intercostal nerves on the dorsal and caudal
aspects of the fourth, fifth and sixth ribs

FIG 1. Preoperative lateral

radiograph. Note the ventral
deviation of the trachea
cranial to the heart,
suggestive of
a retroesophageal left
subclavian artery
Journal of Small Animal Practice

Vol 48
January 2007
2006 British Small Animal Veterinary Association

FIG 2. Preoperative ventrodorsal radiograph.

Note the leftward deviation (arrow) of the
trachea cranial to the heart, indicative of
a persistent right aortic arch

were injected with a total of 2 cc of 0
025

per cent bupivicaine to provide intra- and
postoperative analgesia. Upon entering the
left thoracic cavity, the left cranial lung lobe
was identified, rotated caudally and packed
off in the caudal thorax using a moistened
gause sponge. This revealed a persistent left
azygos vein and a persistent left cranial vena
cava (Fig 3). The persistent left cranial vena
cava was dissected cranial to the left azygos
vein with a right-angled Mixter clamp,
encircled with a silastic loop and retracted
ventrally. Excessive retraction caused an elevation of central venous pressure (measured
fromthecatheterintheleftjugularvein)from
3 cm to more than 15 cm water, indicating
that the left vena cava was the main source
of venous drainage for the head and the
forelimbs. The mediastinum was opened
dorsal to the left vagus nerve for a length
of several centimetres. The vagus nerve
was encircled with a ligature of 3/0 Monocryl (Ethicon, Inc.) and retracted ventrally.
A thrill was palpable in the main pulmonary
artery ventral to its communication with
33

K. J. Christiansen and others

FIG 3. Left fourth

intercostal space
thoracotomy. The persistent
left azygos vein and the
persistent left cranial vena
cava (LCVC) are visible

a large PDA. The aorta was initially not

visible but was palpable in the right mediastinum. The caudal area between the ductus cranially, left main pulmonary artery
ventrally and the aorta dorsally was dissected. Dissection was initially attempted
cranial to the ductus, but exposure was
limited. It was thought that this was
likely due to the cranial tethering effect
of a retroesophageal left subclavian artery.
The aorta was carefully dissected and this
vessel identified. The retroesophageal left
subclavian artery was dissected for a
length of 2 cm and ligated proximally
and distally with two ligatures of 2/0 silk.
A transfixation ligature of 4/0 silk was
placed immediately adjacent to each of
the encircling ligatures and tied (Fig 4).
The subclavian artery was then transected
between the ligatures, allowing the heart,
the aorta and the ductus to move more
caudally into the surgical field. The aorta
caudal to the ductus was then dissected
and encircled with a latex drain. The cranial aspect of the ductus was dissected
using a right-angled Mixter clamp. Dissection of the ductus was continued

until two ductus clamps could be placed

on the PDA from cranial to caudal, leaving enough room between them to transect and oversew the vessel ends (Fig 5).
The pulmonary artery side of the vessel
was oversewn from caudal to cranial
using a simple continuous suture of 5-0
prolene. The suture was tied and a second continuous suture was placed from
cranial to caudal, interlocking with the
first (Fig 6). The cranial and caudal ends
of the knots were left long and used
as stay sutures. The ductus clamp was
released slowly. No haemorrhage was
apparent and the knot ends were cut
short. The aortic side of the vessel was
sutured in a similar manner. When the
ductus clamp was slowly removed from
this side, there was minimal haemorrhage
through the needle holes at the base of
the sutures that ceased after digital pressure was applied to the suture line for two
minutes. A chest tube was placed and the
thorax closed in a routine manner.
Postoperatively, the dog was maintained on a balanced electrolyte solution
with 2
5 per cent 2 ml/kg/hour intrave-

FIG 4. The retroesophageal

left subclavian artery has
been isolated and ligated

34

Journal of Small Animal Practice

nous dextrose for 24 hours. About 0
1

mg/kg every six hours intravenous hydromorphone was administered for pain
relief. Minimal fluid was aspirated from
the chest tube and removed 24 hours after
surgery. The dog was fed a slurry of
canned food while in a vertical position
and had no episodes of regurgitation.
The dog was discharged three days after
surgery. Skin sutures were removed 10
days after surgery.
The dog was re-evaluated three months
after surgery. The dog weighed 22
1 kg
and was active, alert and responsive.
The owner reported that the dog was
eating dry dog food normally, with no
episodes of regurgitation.

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

Vol 48
January 2007
2006 British Small Animal Veterinary Association

Multiple vascular anomalies in a German shepherd puppy

FIG 5. Two ductus clamps

placed on the patent left
ductus arteriosus in
preparation for transection

frequency of anomalous venous drainage

is only 1 per cent but is greater in dogs that
have other transpositional types of anomalies (Buchanan 1963). The embryological
development of the azygos and/or the
hemiazygos veins has been described
and published elsewhere (Campbell and
Deuchar 1954). Sammarco and others
(1995) described a dog with a left azygos
vein that was notable on echocardiography
and radiographs. These findings were not
appreciated in the current case as most of
the abdominal venous return was via the
caudal vena cava and not via the left azygos
vein as reported in the study of Sammarco
and others. Recognition of anomalous
venous drainage is important before cardiac surgery that requires cardiopulmonary bypass, as most bypass procedures
required cannulation of the cranial and
the caudal vena cava for venous drainage
to the bypass pump (Buchanan 1963).
References

FIG 6. The pulmonary

artery side of the ductus
arteriosus is oversewn

the subclavian artery distal to the divided

segment. The ductus arteriosus associated
with a PRAA is often partially patent, but
continuous murmurs rarely are discernable
as the patent ductus blood flow is usually
minimal (Ellison 1980). In a series of
52 dogs with PRAA, six (12 per cent)
had PDAs (Buchanan 2004). Double
ligation and transfixation of the ductus are
recommended even if flow is not apparent
to prevent intra- and postoperative haemorrhage. In the dog described here, the size
of the ductus and the congenital anomalies
present necessitated division and oversewing of the pulmonary and aortic ends.
Ligating the ductus as apposed to transecting the ductus would not remedy the oesophageal constriction and the dog would
continue to regurgitate.
The conformation of the arterial vascular anomalies was suspected from the
physical examination and plain thoracic

Journal of Small Animal Practice

radiographic findings. The continuous

murmur suggested the presence of a large
PDA. The exaggerated ventral deviation of
the trachea on the lateral thoracic radiograph (Fig 1) and the leftward deviation
of the trachea just cranial to the heart on
the ventrodorsal radiograph (Fig 2) were
highly suggestive of a retroesophageal left
subclavian artery and a PRAA, respectively. It is important to note that a retroesophageal left subclavian artery can be
found in as many as 33 per cent and atretic
left arches in an additional 12 per cent of
dogs with PRAA (Buchanan 2004). Failure
to identify and transect these extra constricting vessels or ligaments at surgery
perpetuates oesophageal constriction and
may explain persistent postoperative regurgitation in some dogs (Buchanan 2004).
Dogs normally have a right azygos vein
that joins the cranial vena cava just before
its entrance into the right atrium. The

Vol 48
January 2007
2006 British Small Animal Veterinary Association

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