Ann Thorac Surg 2000;69:621-623
© 2000 The Society of Thoracic Surgeons
Case Reports
Traumatic rupture of an aberrant right subclavian artery
Julian J. Alcocer, MDa,
Laurence Spier, MDa,
Cornelius M. Dyke, MDa,
Bartley P. Griffith, MDa,
James S. Gammie, MDa
a Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
Address reprint requests to Dr Gammie, Division of Cardiothoracic Surgery, University of Massachusetts Medical Center, 55 Lake Ave N, Worcester, MA 01655-0304
e-mail: gammiej{at}ummhc.org
 |
Abstract
|
|---|
We describe a patient who sustained a traumatic rupture of an aberrant right subclavian artery. An interposition graft was used to restore continuity of the artery to the descending thoracic aorta.
|
Introduction
|
|---|
An aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly, with an incidence of 0.6% to 0.8% in the general population [1]. In North America, approximately 1,000 to 1,500 cases of traumatic aortic rupture, primarily because of motor vehicle crashes, are treated annually [2].
A 29-year-old man was a restrained passenger in a motor vehicle crash. On admission he was hemodynamically stable, awake, and complaining of chest pain. Physical examination revealed decreased breath sounds on the left. The chest roentgenogram showed a right first rib fracture, a right pleural cap, a small left hemopneumothorax, and a wide mediastinum. A left chest tube was placed and drained 100 mL of blood. A diagnostic peritoneal lavage was negative. An arteriogram demonstrated the presence of an ARSA originating from the aorta distal to the left subclavian artery. An irregular margin of contrast at the origin of the ARSA was suggestive of a contained rupture (Fig 1). The chest was entered through the left fourth intercostal space. An extensive superior mediastinal hematoma was apparent. The left superior pulmonary vein and the descending thoracic aorta were cannulated, and partial left heart bypass was initiated. The arch, descending aorta, and ARSA were controlled with clamps and the aorta was opened. There was a circumferential intimal tear at the origin of the right subclavian artery. The transection was completed and the aortic defect oversewn. A 10 mm Dacron (C.R. Bard, Haverhill, MA) interposition graft was placed between the ARSA and the aorta (Fig 2). Cross-clamp time was 10 minutes. The patient was discharged without complications on postoperative day 4.
View larger version (110K):
[in this window]
[in a new window]
|
Fig 1. Irregular margin of contrast at origin of the aberrant right subclavian artery suggestive of a contained rupture.
|
|
|
Comment
|
|---|
An ARSA is present in 0.6% to 0.8% of the general population [1]. It results from regression of the right fourth aortic arch between the carotid and subclavian arteries rather than distal to the subclavian artery [3, 4]. The aberrant subclavian artery usually courses upward and to the right, between the spine and esophagus [5]. It is rarely symptomatic [5].
In patients with normal aortic arch anatomy, traumatic rupture of the aorta characteristically occurs at the aortic isthmus, where the aorta is fixed [6]. Shear forces resulting from deceleration of the fluid-filled aortic column are thought to produce an intimal tear at this point of fixation [2]. In the present case, injury was localized to the origin of the ARSA from the aorta. Diagnostic evaluation was similar to that applied to any trauma patient with a suspected blunt aortic injury [6].
Aortography was crucial for detecting the presence of the injury and for defining the vascular anatomy, thereby permitting a rational operative approach. We believe that reconstruction rather than ligation of the ARSA was critical to avoid right arm ischemia. Previous reports have documented a 30% to 45% incidence of limb ischemia in patients undergoing ligation (without reconstruction) of an ARSA [7, 8]. Although the cross-clamp time in this case was brief, we routinely provide active distal circulatory support with partial left heart bypass to all patients undergoing repair of traumatic rupture of the aorta as the optimal means of preventing spinal cord ischemia [9].
In conclusion, we describe the successful surgical management of a patient with traumatic tear of an ARSA. Adherence to accepted principles of diagnosis and repair of traumatic aortic injuries produced an excellent outcome.
|
References
|
|---|
-
Akers D.L., Jr, Fowl R.J., Plettner J., Kempczinski R.F. Complications of anomalous origin of the right subclavian artery. Ann Vasc Surg 1991;5:385-388.[Medline]
-
Fabian T.C., Richardson J.D., Croce M.A., et al. Prospective study of blunt aortic injury. J Trauma 1997;42:374-383.[Medline]
-
Bull P.G., Denck H. Aberrant right subclavian artery. Eur J Vasc Surg 1994;8:757-760.[Medline]
-
Freed K., Low V.H. The aberrant subclavian artery. Am J Roentgenol 1997;168:481-484.[Free Full Text]
-
Kalke B.R., Magotra R., Doshi S.M. A new surgical approach to the management of symptomatic aberrant right subclavian artery. Ann Thorac Surg 1987;44:86-89.[Abstract]
-
Kodali S., Jamieson W.R., Leia-Stephens M., Miyagishima R.T., Janusz M.T., Tyers G.F. Traumatic rupture of the thoracic aorta. A 20-year review. Circulation 1991;84:III40-III46.
-
Lee R., Maughan R.E., Svensson L.G. Elephant trunk reconstruction for aberrant right subclavian and aortic aneurysm. Ann Thorac Surg 1997;64:547-548.[Abstract/Free Full Text]
-
Esposito R.A., Khalil I., Galloway A.C., Spencer F.C. Surgical treatment for aneurysm of aberrant subclavian artery based on a case report and a review of the literature. J Thorac Cardiovasc Surg 1988;95:888-891.[Abstract]
-
Gammie J.S., Shah A.S., Hattler B.G., et al. Traumatic aortic rupture. Ann Thorac Surg 1998;66:1295-1300.[Abstract/Free Full Text]
Accepted for publication June 22, 1999.
Top
Abstract
Introduction
