There is a large variety of aortic arch abnormalities. Important for anaesthesia are complete vascular rings, encircling the trachea, bronchi and oesophagus, causing varying degrees of airway compression, vascular compression and feeding problems. There might be additional cardiac lesions or genetic abnormalities, but the main anaesthetic problem is airway compression and tracheomalacia, which require careful airway management. These children might need higher ventilation pressures with PEEP to overcome the airway compression. Vascular compression might influence pulmonary or upper limb perfusion, which has implications for the positioning of the arms.