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Ann Thorac Surg 1997;64:547-548
© 1997 The Society of Thoracic Surgeons

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Case Reports

Elephant Trunk Reconstruction for Aberrant Right Subclavian and Aortic Aneurysm

Center for Aortic Surgery, Lahey Hitchcock Clinic, Burlington, MA

Accepted for publication March 25, 1997.

	Abstract

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Although an aberrant right subclavian artery is the most common abnormality of aortic arch development, it is an unusual entity to encounter during repair of thoracic aortic aneurysms. A case of an aberrant right subclavian artery requiring reattachment during repair of an ascending aorta, aortic arch, and descending thoracic aortic aneurysm is reported. We report using the modified elephant trunk technique for surgically managing the aneurysm and aberrant right subclavian artery.

	Introduction

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Sudden chest pain of new onset developed in a 65- year-old woman, who was evaluated with an exercise tolerance test. The latter revealed ST segment depression in the inferior leads but no evidence of redistribution on thallium imaging. A cardiac catheterization showed normal coronary arteries but a dilated aortic root measuring 5 cm. The patient was observed for 6 months and then underwent chest computed tomography, which revealed a 7.2-cm-diameter aneurysm of the ascending aorta involving also the transverse arch and the proximal descending thoracic aorta. The latter measured 5 cm. There was no evidence of aortic dissection.

The patient was referred for surgical repair at the Lahey Hitchcock Clinic of her ascending aorta, aortic arch, and proximal descending thoracic aortic aneurysms. Chest computed tomography revealed an asymptomatic aberrant right subclavian artery coursing behind the aortic arch. The aberrant right subclavian artery was observed to originate from the proximal descending thoracic aorta just distal to the takeoff of the left subclavian artery. The origin of the aberrant right subclavian in the proximal descending aorta, known as Kommerell's diverticulum, was aneurysmal, whereas the distal descending thoracic aorta appeared normal.

A median sternotomy was performed, and the aneurysmal ascending aorta was measured to be approximately 7.5 cm and involved the transverse arch. Replacement of the ascending aorta and transverse arch with a 26-mm graft was performed using the modified elephant trunk technique as described by Svensson [1] using deep hypothermia (rectal temperature, 18°C) with circulatory arrest and retrograde brain perfusion. The patient recovered without complication and was discharged on postoperative day 9. Curiously, subsequent histologic examination of the aorta revealed a chronic healing aortic dissection that had not been noted macroscopically, possibly accounting for the original chest pain.

The patient returned 6 weeks later for the second stage of her modified elephant trunk reconstruction of her thoracic aorta. At the operation, the aneurysm was opened without clamping of the aorta and the elephant trunk graft was clamped [1]. A 10-mm Dacron graft was sewn to the nonaneurysmal orifice of the aberrant right subclavian artery, and then the aortic graft was stretched to the appropriate length, cut, and anastomosed to the distal thoracic aorta. The aortic clamp time was 31 minutes. Subsequently, the 10-mm graft was anastomosed to the elephant trunk graft after the application of a side-biting vascular clamp. The elephant trunk Dacron graft and the 10-mm Dacron interposition graft were covered with the aneurysm sac. The patient recovered without any complications and was noted to have equal upper extremity blood pressures. As shown in Figure 1, a postoperative angiogram performed on postoperative day 4 revealed a patent aberrant right subclavian artery. She was discharged on postoperative day 9.

View larger version (83K): [in this window] [in a new window]   Fig 1. . Angiogram (a) and diagram (b) after the completed modified elephant trunk procedure demonstrating the flow to the right subclavian artery.

	Comment

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Since Gross' [3] first description of division of an aberrant right subclavian artery to relieve compression of the esophagus, there are numerous reports in the pediatric surgical literature supporting the idea that division of the subclavian artery without reconstruction (eg, subclavian flap aortoplasty for aortic coarctation) is well tolerated. Long-term follow-up of these pediatric patients, however, has raised concerns of the adequacy of upper extremity perfusion due to the observed differential arm growth [4]. In the adult population, division of the subclavian artery without reconstruction also appears to be much less tolerated [5–8]. Since the principle of subclavian steal was described by Reivich and colleagues [5] in 1961, most reports have stressed the importance of maintaining subclavian artery flow [5–8]. There are several well-described options of reconstruction of symptomatic aberrant subclavian arteries combined with repair of the descending aorta: subclavian–carotid transposition, subclavian–carotid bypass, ascending aorta–subclavian bypass, or subclavian-to-subclavian bypass [7, 8]. In the setting of descending thoracic aortic aneurysm repair, these techniques necessitate a separate incision in addition to the left thoracotomy required for aneurysm repair [8].

This case report describes a method for managing an extensive aneurysm associated with an aberrant subclavian artery that also maintains adequate subclavian artery flow by the use of a short Dacron interposition graft from the subclavian artery to the side of the elephant trunk graft. This technique is advantageous because it enables repair of the extensive aneurysms without requiring a separate neck incision as long as the aberrant artery is not causing compression symptoms such as dysphagia or dyspnea. If the aberrant artery is symptomatic, the other option would be to do an ascending aortic graft to the right subclavian artery bypass graft at the first-stage operation.

	Footnotes

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Address reprint requests to Dr Svensson, Center for Aortic Surgery, Division of Cardiovascular Surgery, Lahey Hitchcock Clinic, 41 Mall Rd, Burlington, MA 01805.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Svensson LG. Rationale and technique for replacement of the ascending aorta, arch, and distal aorta using a modified elephant trunk procedure. J Card Surg 1992;7:301–12.[Medline]
2. Goldbloom AA. The anomalous right subclavian artery and its possible clinical significance. Surg Gynecol Obstet 1922;34:378–84.
3. Gross RE. Surgical treatment for dysphagia lusoria. Ann Surg 1946;124:532–4.[Medline]
4. Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late effects on the left upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1983;85:678–81.[Abstract]
5. Reivich M, Holling HE, Roberts B, et al. Reversal of blood flow through the vertebral artery and its effect on cerebral circulation. N Engl J Med 1961;265:878–9.[Medline]
6. Austin EH, Wolfe WG. Aneurysm of aberrant subclavian artery with a review of the literature. J Vasc Surg 1985;2:571–7.[Medline]
7. Esposito RA, Khalil I, Galloway AC, Spencer FC. Surgical treatment for aneurysm of aberrant subclavian artery based on a case report and a review of the literature. J Thorac Cardiovasc Surg 1988;95:888–91.[Abstract]
8. Svensson LG, Crawford ES. Aortic dissection and aortic aneurysm surgery. Clinical observations, experimental investigations and statistical analyses. Part III. Curr Probl Surg 1993;30:61–5.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert E. Maughan Lars G. Svensson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lee, R. Articles by Svensson, L. G. Search for Related Content PubMed PubMed Citation Articles by Lee, R. Articles by Svensson, L. G.