A DOUBLE aortic arch results in a vascular ring that may compress the trachea and esophagus.1  Although the incidence of double aortic arch is unknown, they represent less than 1% of all congenital heart disease. Symptoms commonly include stridor, dyspnea, cough, recurrent upper respiratory tract infections, dysphagia, and feeding difficulty.1–3  Although more common in children, adults may present with new symptoms or chronic symptoms misdiagnosed as other diseases, as was the case in a 47-yr-old woman who presented with long-standing dyspnea (presumed for decades to be due to asthma) and dysphagia. Her symptoms had progressed to include new orthopnea with inability to lay supine and worsening dysphagia. Three-dimensional volume-rendered (A) and axial (B) contrast-enhanced computerized tomography demonstrated an incomplete double aortic arch with mirror image branching and an atretic left arch segment, with resulting compression and narrowing of the distal trachea and esophagus. After airway topicalization, severe tracheal compression was noted during awake fiberoptic intubation (C) performed in the sitting position. The 7.5-mm endotracheal tube was advanced past the area of tracheal compression, general anesthesia was induced with sevoflurane, and the patient was positioned supine. Operative repair typically consists of division of the lesser or atretic aortic arch via a left thoracotomy, resulting in postoperative symptom resolution.1–3  The potential for tracheal compression resulting in the inability to intubate must be assessed before induction of general anesthesia to ensure safe airway management (fig. left aortic arch [LAA], left common carotid [LCC], left subclavian artery [LSA], right aortic arch [RAA], right common carotid [RCC], right subclavian artery [RSA]).

Competing Interests

The authors declare no competing interests.

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