Ann Thorac Surg 2000;70:1405-1407
© 2000 The Society of Thoracic Surgeons
Case report
Double aneurysms of arch and descending aorta associated with right aortic arch
Tamotsu Yasuda, MDa,
Shinichiro Yamamoto, MDa,
Yoshinori Ishida, MDa
a Department of Cardiovascular Surgery, Fukui Prefectural Hospital, Fukui, Japan
Address reprint requests to Dr Yasuda, Department of Surgery (I), Kanazawa University School of Medicine, Takaramachi 13–1, Kanazawa 920–8641, Japan
e-mail: yasuda{at}sf.m.kanazawa-u.ac.jp
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Abstract
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We report a case of a 69-year-old man in whom double aortic aneurysms of the arch and descending aorta with a right aortic arch and mirror-image branching were diagnosed by three-dimensional computed tomography and aortography. These techniques are useful to assess the exact anatomy of the lesion and branches of the arch. The patient was successfully treated by a two-stage operation consisting of aortic arch replacement followed by descending aorta replacement.
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Introduction
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Aortic arch aneurysm involving the right aortic arch is extremely rare. We report an adult case of double aortic aneurysms of the arch and the descending aorta associated with the right aortic arch that was treated surgically.
A 69-year-old man was referred to our hospital for close examination of hoarseness on June 24, 1998. Chest roentgenogram revealed a normal-sized heart and two bulges along the right side of the mediastinum (Fig 1). Three-dimensional computed tomogram of the thorax revealed a right aortic arch with mirror-image branching and an aortic arch aneurysm (Fig 2). Thoracic aortogram revealed double aortic aneurysms of the arch (52 mm diameter) and descending aorta (50 mm diameter) in the right aortic arch (Fig 3). No other congenital abnormalities were detected by cardiac catheterization or echocardiography.
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Fig 1. Chest roentgenogram showing a normal-sized heart, absence of an aortic knob on the left side, and two bulges along the right side of the mediastinum.
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Fig 2. Three-dimensional computed tomogram showing an arch aneurysm in right aortic arch and the left subclavian artery arising from the left innominate artery.
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Fig 3. Preoperative aortogram in postero-anterior and right anterior oblique views showing double aortic aneurysms of the arch and descending aorta, and mirror-image branching type of right aortic arch.
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We performed a two-stage operation consisting of aortic arch replacement followed by descending aorta replacement. The patient underwent the first operation on September 8. By median sternotomy, the ascending aorta and right aortic arch were exposed with division of the left innominate vein. To prevent cerebral embolism caused by retrograde femoral inflow, the arterial cannula was inserted into the ascending aorta 2 cm upstream from the arch aneurysm. The two-staged venous cannula was inserted into the right atrium.
The patient was placed on cardiopulmonary bypass and core cooled. After the nasopharyngeal temperature dropped to 20°C, the arch aneurysm was incised under hypothermic circulatory arrest. By cannulation into the left innominate artery and the right common carotid artery, selective cerebral perfusion was started with perfusion pressure between 40 mm Hg and 50 mm Hg. A piece of 24 mm woven Dacron graft with 4 sidearm grafts was prepared. We selected a distal anastomosis line 2 cm downstream from the right subclavian artery and performed distal graft-to-aorta anastomosis using intermittent everted mattress sutures with pledgets.
After systemic circulation was restarted using a sidearm graft as the route of arterial inflow, we reconstructed the right subclavian artery, the right common carotid artery, and the left innominate artery with individual sidearm grafts. Proximal aorta-to-graft anastomosis using 3-0 polypropylene continuous suture was performed 5 cm above the coronary ostia. Finally, the left innominate vein was reconstructed.
The postoperative course was uneventful without any adverse neurologic symptoms. The patient underwent a second operation on November 17. By right posterolateral thoracotomy, the descending aorta was exposed and cross-clamped 5 cm upstream and downstream from a saccular aneurysm under femorofemoral cardiopulmonary bypass. The aneurysm was opened, and mural thrombi were observed. The descending aorta measuring 6 cm in longitudinal length was totally replaced with a 24 mm woven Dacron graft with the distal anastomosis constructed above the diaphragm. Postoperative aortogram revealed smooth blood flow in right aortic arch, arch vessels, and the descending aorta. The patient was discharged on postoperative day 73, to the care of his referring physician because of need to control his blood glucose.
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Comment
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Right aortic arch is an uncommon anomaly, with an incidence of about 0.1% in the general population [1]. It is classified according to the origin of the branches of the arch as follows: (1) mirror-image branching, (2) aberrant left subclavian artery, and (3) isolation of left subclavian artery. We reported a case of type 1 complicated double aortic aneurysms of the arch and descending aorta in an adult free of other congenital abnormalities. However, this type is closely associated with cyanotic congenital heart disease, the most common type of which is the tetralogy of Fallot [2]. Vascular abnormalities that should be considered in the differential diagnosis of arch aneurysms associated with a right aortic arch include Kommerell’s diverticulum and ductus diverticulum [3]. In this case, the left subclavian artery arose from the left innominate artery and the remnant of the ductus arteriosus was not detected during the operation. Therefore, this case was considered to be unlike previously reported cases.
Several cases have been reported in which true aortic aneurysms involving a right aortic arch were treated surgically [4–6]. However, this case is extremely rare because true arch aneurysm involved a right aortic arch with mirror-image branching. We performed the hypothermic circulatory arrest in addition to selective cerebral perfusion during aortic arch replacement because antegrade perfusion was sometimes interrupted during reconstruction of the arch vessels. We believe that selective cerebral perfusion is more reliable than retrograde cerebral perfusion through the superior vena cava. In this case the arch vessels were reimplanted separately. The left innominate artery was too distant from the right common carotid artery to reconstruct the arch vessels through a single aortic cuff. Three-dimensional computed tomography and angiography are useful to assess the exact anatomy of the lesion and the branches of the arch and to plan the surgical intervention. As the curvature of a right aortic arch is commonly higher than that of the left aortic arch, division of the left innominate vein was needed.
We elected to perform a two-stage operation. A simultaneous procedure by median sternotomy or right lateral thoracotomy was considered to be more invasive because distal aorta-to-graft anastomosis of descending aorta replacement may be just above the diaphragm. In addition, arch replacement is preliminary to descending aorta replacement to prevent cerebral embolism because of thrombi of the descending aneurysm using retrograde femoral inflow. Endovascular stent-graft placement for descending saccular aneurysm was not indicated because bilateral external iliac arteries were markedly kinked in this case.
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References
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Shuford W.H., Sybers R.G. Right aortic arch. In: Shuford W.H., Sybers R.G., eds. The aortic arch and its malformations. Springfield, IL: Charles C. Thomas, 1974:52-68.
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Salomonowitz E., Edwards J.E., Hunter D.W., et al. The three types of aortic diverticula. Am J Roentgenol 1984;142:673-679.[Free Full Text]
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Patiniotis T.C., Mohajeri M., Hill D.G. Right aortic arch with aberrant left subclavian artery. Aust NZ J Surg 1995;65:690-692.[Medline]
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Svensson LG, Crawford ES. Cardiovascular and vascular disease of the aorta. Philadelphia: WB Saunders, 1996:164–71.
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Wakiyama H., Okada M., Yamashita C., et al. Successful surgical treatment of an Edwards type IIIB right aortic arch aneurysm. Surg Today 1998;28:1098-1101.[Medline]
Accepted for publication January 15, 2000.
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Abstract
Introduction
