J Thorac Cardiovasc Surg 2006;132:689
© 2006 The American Association for Thoracic Surgery
Acute type B dissection with involvement of an aberrant right subclavian artery: An unusual presentation and a diagnostic challenge
Jayesh Dhareshwar, MD,
Anthony L. Estrera, MD*,
Eyal E. Porat, MD,
Ali Azizzadeh, MD,
Hazim J. Safi, MD
Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston Medical School, Memorial Hermann Hospital, Houston, Tex.
Received for publication April 5, 2006; accepted for publication April 20, 2006.
* Address for reprints: Anthony L. Estrera, MD, Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Center at Houston Medical School, 6410 Fannin Street, Suite 450, Houston, TX 77030 (Email: Anthony.l.estrera{at}uth.tmc.edu).
A 49-year-old hypertensive man was transferred to our institute with symptoms of acute-onset chest pain and hypotension, and computed tomography scan findings of an acute aortic dissection. On detailed review of the computed tomography scan images, the diagnosis was made of a type B aortic dissection with an intimal flap extending into an aberrant right subclavian artery arising from the descending thoracic aorta. This was confirmed with a transesophageal echocardiography. The patient was managed successfully with medical therapy.
An aberrant right subclavian artery arising from a left-sided aortic arch, also known as arteria lusoria, is the fourth most common aortic arch anomaly. It has a reported incidence of 0.5% to 2%.1,2
The aberrant artery usually follows a retroesophageal course; rarely, it takes a course anterior to the esophagus or trachea. Most patients with an aberrant right subclavian artery remain asymptomatic; however, progressive dysphagia develops occasionally (dysphagia lusoria). Aneurysm of the aberrant artery, which is well known for early rupture, is an occasional indication for intervention.3
The association of dissection and aberrant right subclavian artery is rarely encountered; however, the diagnostic and therapeutic implications of these associations are important and potentially ominous. Preoperative diagnosis of aberrant right subclavian artery is important for both open surgical and endovascular repair. High-resolution multislice computed tomography scan imaging is useful for a precise assessment of the involved aberrant artery.4 (Figure 1).
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Figure 1. Contrast-enhanced computed tomography scan with 3D reconstruction showing acute type B dissection of the aorta. Bold arrows point to the dissecting flap extending into the aberrant right subclavian artery originating from the descending thoracic aorta.
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References
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- Kalke BR, Magotra R, Doshi SM. A new surgical approach to the management of symptomatic aberrant right subclavian artery. Ann Thorac Surg 1987;44:86-89.[Abstract/Free Full Text]
- Kiernan PD, Dearani J, Byrne WD, Ehrlich T, Carter W, Krasicky G, et al. Aneurysm of an aberrant right subclavian artery: case report and review of the literature. Mayo Clin Proc 1993;68:468-474.[Medline]
- Kwok PC, Ho KK, Tse CW, Siu KW, Tsao JP, Cheung JY. Role of multidetector computed tomography in stent-graft repair of type B aortic dissection in a patient with an aberrant right subclavian artery. J Endovasc Ther 2005;12:621-623.[Medline]
