Ann Thorac Surg 1995;59:520-522
© 1995 The Society of Thoracic Surgeons
Case Reports
Systemic–Pulmonary Shunt With a Right Retroesophageal Subclavian Artery
Benoit Legault, MD,
Lionel Camilleri, MD,
Patrick Bailly, MD,
Isabelle Brazzalotto, MD,
Jean-René Lusson, MD,
Charles de Riberolles, MD
Department of Cardiovascular Surgery, Gabriel Montpied Hospital, Clermont-Ferrand, France
Accepted for publication June 6, 1994.
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Abstract
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A 19-day-old child suffering from cyanosis due to tetralogy of Fallot was palliated by using his right retroesophageal subclavian artery. It was anastomosed side-to-side onto the ascending aorta and end-to-side onto the right pulmonary artery. The palliation obtained with this systemic-pulmonary shunt was satisfying. The right brachial vascular flow was normal.
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Introduction
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Right retroesophageal subclavian artery is a frequent defect of the aortic arches, occurring in about 0.3% of living infants [1]. Occasionally, it is associated with other malformations such as tetralogy of Fallot and coarctation [2]. Rising from the descending thoracic aorta distal to the left subclavian artery, it passes through the posterior mediastinum behind the esophagus to join again its normal course toward the right arm.
Frequently, the length of its intrathoracic course allows its reimplantation onto the ascending aorta as well as the creation of a systemic–pulmonary shunt between the ascending aorta and the right pulmonary artery. This technique, performed on the 19th day of life in a case of tetralogy of Fallot, provided a satisfactory palliation with a total cure at 20 months without jeopardizing right arm vascularization.
A full-term florid female patient (3 kg, 50 cm) was examined during the neonatal period for cyanosis. Clinical, radiologic, and electrical patterns were consistent with the diagnosis of tetralogy of Fallot. A cardiac echography diagnosed a large right ventricular outlet juxtaarterial ventricular septal defect. There was a more than 50% aortic dextroposition with side-by-side aortic and pulmonary ring. Pulmonary annulus was 3 mm in diameter, pulmonary arterial trunk, 6 mm, and right and left branches, 3 mm. The arterial duct was patent on Doppler examination. Aortography revealed a left cervical aortic arch. The right subclavian artery rose from the descending thoracic aorta (Fig 1
). The left carotid artery bifurcation was intrathoracic, and a left vertebral artery branching off directly from the aorta was noted.
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Fig 1. . Preoperative aortography at 1 month of life. Opacification of the right retroesophageal subclavian artery is visible.
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On the 19th day of life, a systemic–pulmonary shunt was achieved using the right subclavian artery. Through a right thoracotomy, the right subclavian artery was divided at its origin. Its intrathoracic course was dissected free and mobilized to the base of its first two branches, which were divided. The proximal end of the right subclavian artery was implanted end-to-side onto the right pulmonary artery. A side-to-side anastomosis between the right subclavian artery and the ascending aorta supplied the subclavian artery and the systemic-pulmonary shunt (Fig 2). Postoperative evolution was uneventful. Shunt patency was confirmed by Doppler examination. The palliation obtained with this systemic–pulmonary shunt allowed us to wait until the age of 20 months before reexamining the child for slowing down of growth. The systemic–pulmonary shunt was found patent without stenosis, allowing a harmonious growth of the pulmonary arterial trunk. On cineangiography, the contrast medium injection into the ascending aorta filled the right subclavian artery and the systemic–pulmonary shunt very well (Fig 3). During the surgical cure, before cardiopulmonary bypass, it was easy to control the subclavian portion between the ascending aorta and the pulmonary artery. The ventricular septal defect was closed by a 20-mm-diameter Dacron patch. The right ventricular outflow tract was enlarged using an infundibulopulmonary transannular Dacron patch, so the pulmonary annulus size was increased from 3 to 12 mm. The infant was discharged from the hospital on postoperative day 15 to an uneventful evolution. Two years later, she was still asymptomatic without any treatment. The development of her right upper limb was normal and arterial pressure was similar in both arms. The vascular flow of her right upper limb was normal on Doppler examination.
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Fig 2. . Operative technique: parallel, side-to-side anastomosis between the right subclavian artery (RSA) and the ascending aorta (AO). Transverse, end-to-side anastomosis between the proximal end of the right subclavian artery and the right pulmonary artery (PA) forms a systemic pulmonary shunt (SPS).
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Fig 3. . Postoperative aortography during a left ventriculography at 20 months of life. Opacification through the aortic side-to-side anastomosis of the right subclavian artery and the right pulmonary branches is visible.
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Comment
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The right retroesophageal subclavian artery is a vascular sling. In childhood, airways obstruction and dysphagia are rare. Usually, the right retroesophageal subclavian artery is diagnosed during evaluation to uncover other abnormalities [2, 3]. Dysphagia may arise in infancy when a right subclavian artery and a supraaortic vessel abnormality such as common carotid trunk happen together [4, 5]. Symptoms may also occur in the postoperative course of an arterial duct ligature [6, 7] or in a radical treatment of a tetralogy of Fallot [7] when the anomalous subclavian artery is unknown preoperatively. Taking these findings into account, the section of a known right retroesophageal subclavian artery seems to be justified.
If simple section of a right retroesophageal subclavian artery is conceivable [8], this sacrifice may provoke vascular flow alteration, abnormal upper-arm growth (mainly when section is performed in neonatal period), and in some cases, ischemic manifestations during physical exercises [9].
In our case, 3 mm echographic and angiographic measurement of each pulmonary branch, confirmed during palliative operation, led us to prefer a two-step surgical treatment. The palliative step consisted of a systemic–pulmonary shunt through a right thoracotomy. The proximal end of the right retroesophageal subclavian artery was anastomosed to the right pulmonary artery. Because of the very high location of the aortic arch and the supraaortic vessels position, it was not possible to reproduce Yamaguchi and associates' technique [6] as intended, which consists of side-to-side anastomosis of the right subclavian artery to the right carotid artery. The side-to-side anastomosis was performed onto the ascending aorta without any special difficulty.
This technique offers all the advantages of the Blalock-Taussig classic anastomosis: efficient palliation, easy control during reoperation, and harmonious development of the pulmonary arterial trunk. Furthermore, it preserves a normal brachial arterial flow and prevents further possible risks of tracheo–esophageal compression.
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Footnotes
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Address reprint requests to Dr Camilleri, Service de Chirurgie Cardiovasculaire, Hopital Gabriel Montpied, Place Henri Dunant, 63003 Clermont-Ferrand Cedex, France.
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References
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- Dupuis C, Kachaner J, Freedom RM, Payot M, Davignon A. Anomalies des arcs aortiques. In: Dupuis C, Kachaner J, Freedom RM, Payot M, Davignon A, eds. Cardiologie pédiatrique (2nd ed). Paris: Flammarion, 1991:457–68.
- Desbaillets P, Schmuziger M, Sadeghi H. Anomalies des arcs aortiques. In: Gerard R, Louchet E, eds. Précis de cardiologie de l'enfant. Paris: Masson, 1973:275–81.
- Stone WM, Brewster DC, Moncure AC, Franklin DP, Cambria RP, Abbott WM. Aberrant right subclavian artery: varied presentations and management options. J Vasc Surg 1990;11:812–7.[Medline]
- Hartyanszky IL, Lozsadi K, Marcsek P, Hüttl T, Sapi E, Kovacs AB. Congenital vascular rings: surgical management of 111 cases. Eur J Cardiothorac Surg 1989;3:250–4.[Abstract]
- Igci A, Kalayci G, Baktiroglu S, Bozfakioglu Y, Ercan E, Müslümanoglu M. Dysphagia lusoria. J Thorac Cardiovasc Surg 1993;105:1116–7.[Medline]
- Yamaguchi M, Obo H, Oshima Y, Ohashi H, Hosokawa Y, Tachibana H. A new technique for use of an anomalous subclavian artery for a systemic–pulmonary arterial shunt. J Thorac Cardiovasc Surg 1989;97:110–3.[Abstract]
- Leijala M, Sairanen H, Mäkinen L, Maunuksela EL, Louhimo I. Iatrogenic, unexpected and other vascular rings in children. Eur J Cardiothorac Surg 1989;3:125–9.[Abstract]
- De Leval M. Vascular rings. In: Stark J, de Leval M, eds. Surgery for congenital heart defects. London:Grune & Stratton, 1983:227–34.
- Van Son JAM, van Asten WNJC, van Lier HJJ, et al. Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy. Circulation 1990;81:996–1004.[Abstract/Free Full Text]
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Abstract
Introduction
