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J Thorac Cardiovasc Surg 1994;107:1469-1471
© 1994 Mosby, Inc.

SURGERY FOR ACQUIRED HEART DISEASE

Surgical management of aneurysms at the origin of an aberrant right subclavian artery

Michel W. Verkroost , MD, Ruben P. Hamerlijnck , MD, PhD, Freddy E. Vermeulen , MD


Nieuwegein, The Netherlands

From the Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.

Received for publication April 24, 1991. Accepted for publication Oct. 5, 1993. Address for reprints: Michel W. Verkroost, MD, St. Antonius Hospital, P.O. Box 2500, 3430 EM, Nieuwegein, The Netherlands.

Abstract

An aneurysmal origin of an aberrant right subclavian artery should preferably be closed with a prosthetic patch inserted with the aid of cardiopulmonary bypass with deep hypothermia and circulatory arrest. Three patients were operated on: a transaortic approach was used in two and a transaneurysmal approach in one. This technique allows a single-stage surgical correction of this rare anomaly through a median sternotomy and obviates the need for hazardous and difficult side clamping of the aorta. (J THORAC CARDIOVASC SURG 1994;107:1469-71)

Several types of congenital vascular anomalies produce partial or total encirclement of the trachea and esophagus. These vascular rings, slings, and other abnormalities of the aortic arch rather frequently lead to dysphagia or dyspnea with stridor, or both.

A left-sided aortic arch with an aberrant right subclavian artery, as first described by Hunauld,Go 1 is the most common aortic arch anomaly, occurring in approximately 0.5% of the population.Go 2 The second most common aortic arch anomaly is caused by persistence of both the right (posterior) and left (anterior) fourth branchial arches. The majority of patients with this anomaly have anatomic continuity but luminal atresia of the anterior arch.

Aneurysms in the course of an aberrant right subclavian artery are not frequently encountered.Go 3 Between 1956 and 1990 only 39 cases were reported.Go Go 4,5 An aneurysm at the very origin of an aberrant right subclavian artery is rare, with only four cases reported until now.Go Go 6-9 In the St. Antonius Hospital, in a 6-year period, we have operated on three patients with this latter combination of anomalies. To our belief repair of this rare entity necessitates a specific surgical technique of patch closure with the aid of deep hypothermia and circulatory arrest.

METHODS AND RESULTS

In our three patients a mass was visible in the upper part of the mediastinum on the chest x-ray films. Computed tomographic scans of the mediastinum and intraarterial angiograms revealed a large aneurysm at the origin of an aberrant right subclavian artery in two patients (both 68 years of age) (Fig. 1) and a double aortic arch with atresia of the anterior arch and a large aneurysm originating from the dorsal aortic arch in the third patient (47 years of age). The first two patients had dysphagia, and the third had progressive swelling of the head and neck because the aneurysm was compressing the superior vena cava.



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  		Fig. 1. Preoperative oblique digital substraction angiogram of the aortic arch. Arrows indicate the aneurysm (measuring 40 mm) at the origin of the arch.

 
In all patients the operation was done through a median sternotomy. The incision was extended into the right supraclavicular region. Cardiopulmonary bypass was established by cannulation of the right common femoral artery and the right atrium. After the patient was cooled by extracorporeal circulation to a nasopharyngeal temperature of 12° C and a rectal temperature of 24° C, circulatory arrest was induced. The ascending aorta and arch vessels were clamped. In the two patients in whom the aneurysm was at the origin of the aberrant right subclavian artery, a longitudinal incision was made in the aortic arch starting at the right common carotid artery and extending to just distal to the origin of the aberrant right subclavian artery, which is the last major branch of the thoracic descending aorta. The presence of true aneurysms was confirmed. The origin of the aneurysm was subsequently closed with a gelatin-sealed (Gelseal, Vascutek, Inchinnan, Renfrewshire, U.K.) prosthetic patch with 4-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, N.J.). The origins were 4 and 3 cm in diameter. The continuity with the distal right subclavian artery was restored afterward with an 8 mm Gelseal interposition graft that was proximally anastomosed to the ascending aorta in one patient (Fig. 2) and to the right common carotid artery in the other patient (Fig. 3). In the patient with aneurysmal origin of the right subclavian artery from the dorsal aortic arch, the origin of the aneurysm was closed during a circulatory arrest of 35 minutes through the aneurysm. A 4 by 3 cm Gelseal prosthetic patch was inserted with running 4-0 Prolene sutures. The circulation to the distal right subclavian artery was restored with an 8 mm Gelseal interposition graft proximally anastomosed to the ascending aorta. The right vertebral artery was reimplanted into the prosthesis, and the origin of the right internal mammary artery was oversewn. In none of the patients was the aneurysm excised.



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  		Fig. 2. Postoperative digital substraction angiogram showing the interposition graft (arrow) between the ascending aorta and the distal right subclavian artery.

 


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  		Fig. 3. Postoperative digital substraction angiogram of the interposition graft (arrow) between the right common carotid artery and the distal right subclavian artery.

 
The postoperative course was uneventful in the first two patients. The third patient had diffuse encephalopathy that had almost completely resolved at discharge on the twenty-first day after the operation. All patients had excellent pulsations and equal blood pressures in both the brachial and radial arteries. Postoperative angiograms in the third patient showed a good result (Fig. 4). In none of the patients did we encounter detrimental sequelae resulting from retention of the aneurysm.



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  		Fig. 4. Postoperative intraarterial angiogram showing the interposition graft (small arrows) between the ascending aorta and distal right subclavian artery. Note the reimplantation of the right vertebral artery (large arrow).

 
DISCUSSION

In children the aberrant right subclavian artery is soft and pliable, whereas by late adolescence the development of atherosclerotic rigidity, tortuosity, and dilation of its origin may result in compression of the esophagus or superior vena cava, as occurred in our three patients.Go 10

The surgical approach in four patients with an aneurysmal origin of an aberrant right subclavian artery so far described in the literature consisted of the following: a left thoracotomy in two patients (one in combination with a right supraclavicular incision), a right thoracotomy in one patient,Go Go 6-8 and in the fourth patient a technique similar to the one that we described, namely, median sternotomy with a transaortic approach to the aneurysm with deep hypothermia and circulatory arrest.Go 9 In the fourth patient the operation was combined with myocardial revascularization.

We used a one-stage approach through a median sternotomy with deep hypothermia and circulatory arrest to facilitate a good exposure of the orifices of the aneurysm, either transaortically or through the aneurysm. Such an approach also obviates the need for difficult and hazardous clamping of the aorta around the base of the aneurysm, which is likely to be calcified in these generally older patients. In addition, the (peri)aneurysmal aortic tissue is frequently fragile. Extension of the incision into the right supraclavicular region adequately exposes the distal right subclavian artery and facilitates restoration of its circulation by insertion of an interposition graft that can be anastomosed to the ascending aorta or the right common carotid artery.

Profound hypothermia with circulatory arrest is the most common method of cerebral protection during operations on the aortic arch. Alternatively, as we currently favor, selective cold cerebral perfusion by cannulation of one or both carotid arteries with profound corporeal hypothermia and circulatory arrest can be performed. The latter technique may be safer in older patients or in complex arch operations with expected long arrest times. Another alternative for cerebral protection with cold cerebroplegia was recently described by Bachet and associates.Go 11

References

  1. Hunauld. Examen de quelques parties d'un signe. Hist Acad R Sci 1735;2:516-23.
  2. Klinkhamer AC. Esophagography in anomalies of the aortic arch system. Baltimore: Williams & Wilkins, 1969:16-30, 64-5.
  3. McCollum CH, De Gama AD, Noon GP, DeBakey ME. Aneurysm of the subclavian artery. J Cardiovasc Surg 1979;20:159-64. [Medline]
  4. Jauch K-W, Riel K-A, Lauterjung L, Berger H. Aneurysmen der Arteria Lusoria. Falldarstellung und literaturübersicht. Chirurgie 1988;59:418-24.
  5. Stone WM, Brewster DC, Moncure AC, et al. Aberrant right subclavian artery: varied presentations and management options. J Vasc Surg 1990;11:812-7. [Medline]
  6. McCallen AM, Schaff B. Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-3.
  7. Hunter JA, Dye WS, Javid H, Najafi H, Julian OC. Arteriosclerotic aneurysm of anomalous right subclavian artery. J THORAC CARDIOVASC SURG 1970;59:754-8. [Medline]
  8. Campbell CF. Repair of an aneurysm of an aberrant retroesophageal right subclavian artery arising from Kommerell's diverticulum. J THORAC CARDIOVASC SURG 1971;62:330-4. [Medline]
  9. Baillot RG, Beven EG, Cosgrove DM. Aneurysm of an aberrant right subclavian artery: repair using circulatory arrest. Cleve Clin Q 1984;51:173-5. [Medline]
  10. van Son JA, Vincent JG, van Oort A, Lacquet LK. Translocation of aberrant right subclavian artery in dysphagia lusoria in children through a right thoracotomy. Thorac Cardiovasc Surg 1989;37:52-4. [Medline]
  11. Bachet J, Guilmet D, Goudot B, et al. Cold cerebroplegia: a new technique of cerebral protection during operations on the transverse aortic arch. J THORAC CARDIOVASC SURG 1991;102:85-94.[Abstract]



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