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J Thorac Cardiovasc Surg 2007;133:800-801
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiac Surgery, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy
b Department of Radiology, University of Bologna, Policlinico S.Orsola-Malpighi, Bologna, Italy.
Received for publication September 21, 2006; accepted for publication October 23, 2006. * Address for reprints: Luca Botta, MD, Cardiac Surgery Department, University of Bologna, Policlinico S.Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy. (Email: allucbot{at}tiscali.it).
Extensive thoracic aortic aneurysms that involve ascending, arch, and descending segments require challenging repairs associated with substantial morbidity and mortality. Since 1983, staged repair with the elephant trunk technique (ETT) has been the standard procedure for managing these aneurysms.1
The aberrant right subclavian artery (ARSA) is a rare entity with a reported prevalence as high as 2%. Aneurysms of the ARSA can cause serious complications. They require surgical treatment, but surgical strategies are still unclear.2 In this report, we propose a 3-stage approach for this complex entity.
A 64-year-old woman was referred to our department for treatment of an extensive aneurysm of the entire thoracic aorta involving the ARSA. Surgical strategy comprised 3 steps. The first step was replacement of the ascending aorta and aortic arch with the ETT and with antegrade selective cerebral perfusion. A trifurcated prosthesis was used and a separate reimplantation of the supraortic vessels was performed. A computed tomographic scan at 1 month’s follow-up demonstrated the 6-cm pre-existent aneurysm of the distal arch and of the descending thoracic aorta (DTA) and the ARSA arising from an aneurysmal dilatation of its origin, the diverticulum of Kommerell (Figure 1, a). Angiography also showed a severe stenosis of the left subclavian artery. Three months later the patient underwent a bilateral subclavian-carotid bypass as second step. Left subclavian–left common carotid artery bypass was performed to solve subclavian steal syndrome and right subclavian–right common carotid artery bypass to prepare the patient for the last step of the procedure: stent grafting of the DTA. The ARSA was ligated just proximal to the right vertebral artery. Endovascular stent-graft repair was successfully performed 1 month later. The elephant trunk was used as landing zone for the endograft. The patient had a smooth recovery and was discharged on the seventh postoperative day. A computed tomographic scan performed at 6 months’ follow-up revealed a complete exclusion of the DTA aneurysm involving the origin of the ARSA (Figure 1, b).
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Surgical treatment of diffuse aneurysms of the thoracic aorta represents an exciting challenge for cardiovascular surgeons. Since the introduction of the ETT by Borst and colleagues3 in 1983, the "2-step" repair has been the standard approach for managing these aneurysms. Nevertheless, several authors have advocated single-stage repairs of the entire thoracic aorta because of the risk of death that exists while awaiting the second procedure.1 The appropriate interval between operations is hard to define; LeMaire, Carter, and Coselli1 have advocated a 6-week recovery period whereas Safi and colleagues4 recommend performing the second-stage repair 4 weeks after the first stage. In patients who have had elephant trunk repair of the arch, a second-stage surgical approach via a left thoracotomy for the replacement of the DTA is usually performed. On the other hand, several groups have reported using endografts to complete the second stage of the procedure.1,5 We chose endoluminal repair of the DTA aneurysm because we believed that it reduced procedural time, blood loss, length of intensive care unit stay, and hospital stay and that it is associated with lower rates of morbidity and mortality if compared with conventional open surgical procedures.
In our patient, the presence of an aneurysmal dilatation of ARSA origin made management of this already complex pathologic condition even more complicated. Most patients with ARSA are asymptomatic, but aneurysms in this location require surgical treatment since they can cause serious complications: distal embolization, rupture, and compression of neighboring structures.2,6 Because of the rareness of the ARSA aneurysms, surgical strategies are still unclear. We have performed a bilateral subclavian-carotid bypass after ETT to prepare the patient for the last step of the procedure: stent grafting of the DTA. We have modified the conventional 2-step repair of thoracic complex aneurysms adding a third stage to suit the peculiar features of our patient. The 3-stage approach has been effective and we believe that it can be safely performed in patients with diffuse aneurysms of the thoracic aorta involving an ARSA. Long-term evaluation in larger numbers of patients is necessary to verify the efficacy of this technique.
References
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