Ann Thorac Surg 2001;71:1710-1711
© 2001 The Society of Thoracic Surgeons
How to do it
Surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery
Takuro Tsukube, MDa,*,
Keiji Ataka, MDa,
Masahiro Sakata, MDb,
Noboru Wakita, MDb,
Yutaka Okita, MDa
a Department of Surgery, Division II, Kobe University, School of Medicine, Kobe, Japan
b Department of Cardiothoracic Surgery, Kobe Rosai Hospital, Kobe, Japan
Accepted for publication November 14, 2000.
* Address reprint requests to Dr Tsukube, Department of Surgery, Division II, Kobe University, School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan (Email: ttsukube{at}med.kobe-u.ac.jp).
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Abstract
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A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell’s diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.
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Introduction
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Right-sided aortic arches are uncommon (0.05% of the population), and reports of surgical repairs of thoracic aortic aneurysms associated with right-sided aortic arches have been rare. Of these, 6 patients with a saccular aneurysm including Kommerell’s diverticulum, and an aberrant left subclavian artery (ALSA), underwent graft replacements of the aortic arch [1–3]. Recently, we performed surgical repairs for 3 patients with Edwards type IIIB right aortic arch aneurysm [4], and tubular graft replacements were successfully performed using three different cardiopulmonary bypass techniques. The aim of this brief article is to describe the surgical technique of this lesion.
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Technique
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A right thoracotomy through the fourth intercostal space was performed. The right phrenic nerve and the superior vena cava were retracted anteriorly. Distal portion of the right-sided aortic arch was exposed from the origin of the right carotid artery. The right vagus was descending at the anterior portion of the aortic arch (Fig 1A). Right atrial and right femoral arterial cannulation were performed and partial cardiopulmonary bypass (CPB) with mild hypothermia (32°C) was initiated. The ascending aortic pressure was monitored during the procedure. After epiaortic ultrasound scans showed minimal atherosclerotic changes in the aortic arch, the aorta was clamped proximal to the right subclavian artery (RSA) and at the descending aorta. In addition, the RSA was clamped at its origin. A longitudinal incision of the aneurysm was performed, and inside Kommerell’s diverticulum and the orifice of the ALSA, at the bottom of the diverticulum, were exposed. The ALSA was occluded intraluminally using a 5-F arterial occlusion catheter (Fig 1B). The ALSA orifice was anastomosed to a woven double-velour Dacron graft (Intergard Collagen Impregnated Woven Dacron Graft, Intervascular Inc, Tampa, FL) of 10-mm in a diameter by inclusion technique. Then a woven double-velour Dacron of 26-mm in diameter was anastomosed to the arch distal to the RSA. The proximal end of the 10-mm woven Dacron graft was anastomosed to the 26-mm Dacron graft by end-to-side fashion (Fig 1C). Finally, the distal end of the 26-mm Dacron graft was anastomosed to the descending aorta (Fig 1C). The CPB time was 129 minutes.
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Fig 1. (A) Operative view of the right-sided aortic arch aneurysm through a right thoracotomy and line of incision of the aneurysm were demonstrated. (B–D) The steps in the repair, using partial cardiopulmonary bypass with reimplantation of the aberrant left subclavian artery with an interposition tube graft. The aortic arch, the descending aorta, and the right subclavian artery were clamped, and a balloon occlusion of the aberrant left subclavian artery was applied. (ALSA = aberrant left subclavian artery; LCA = left carotid artery; RCA = right carotid artery; RSA = right subclavian artery; V = right vagus.)
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Three patients with Edward type IIIB right aortic arch and enlargement of Kommerell’s diverticulum were treated surgically (Fig 2). A median sternotomy was used in the first patient. However, additional right thoracotomy was required because of the acute angulation of the right aortic arch. A right thoracotomy through the fourth intercostal space was selected in the remaining 2 patients. Deep hypothermia (16°C) with circulatory arrest (DHCA) and selective antegrade cerebral perfusion were used in the first patient, and DHCA and retrograde cerebral perfusion were used in the second patient. In both patients, DHCA was used to avoid clamping of the atherosclerotic aortic arch. In the first patient, the selective antegrade cerebral perfusion and CPB times were 106 minutes and 246 minutes, respectively and in the second patient, the retrograde cerebral perfusion and CPB times were 22 minutes and 229 minutes, respectively. In the third patient, as the aortic wall of the arch was minimally diseased, partial CPB was chosen as previously described. All patients survived the operations, and were discharged home without any neurological complications.
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Fig 2. Computed tomography (left) and digital subtraction angiography (right) of patient 3 demonstrated a right-sided aortic arch (Edwards type III B) and a saccular aneurysmal formation of Kommerell’s diverticulum with a maximal diameter of 55 mm. (ALSA = aberrant left subclavian artery; LCA = left carotid artery; RCA = right carotid artery; RSA = right subclavian artery.)
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Comment
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Right aortic arch with ALSA is an uncommon arch anomaly, occurring in about 0.05% of the population [2]. In this anomaly the first branch arising from the aortic arch is the left carotid artery, followed by the right carotid artery, RSA, and left subclavian artery (in that order) [4]. Aortic aneurysms related to the right aortic arch are even more rare. An aneurysm located at the base of the ALSA, Kommerell’s diverticulum, is well known to cause tracheal compression or dysphagia.
Surgical approach to the aneurysm of right-sided aortic arch, especially around the ALSA or enlarged Kommerell’s diverticulum, was not simple. Exposure of the distal portion of the right-sided aortic arch from the midsternotomy was suboptimal because of its acute angulation. Right thoracotomy is the preferred approach for this lesion because it gives good exposure of the ascending aorta through to the descending aorta.
Naturally, brain protection during the procedure in the right-sided aortic arch is necessary, as well as it is in the normal arch. In our patients, DHCA with selective antegrade cerebral perfusion was used in the first patient and DHCA with retrograde cerebral perfusion was used in the second patient. In both patients, DHCA was used to avoid clamping of the sclerotic aortic arch and there were no neurological deficiencies noted. However, if atherosclerotic changes of the aortic arch are mild, partial CPB with clamping at the RSA, the aortic arch, and the descending aorta, with a balloon occlusion of the ALSA are a safe and simple procedure to be applied to this type of lesion.
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References
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- Cooley AD, Mullins CE, Gooch JB. Aneurysm of right-sided cervical arch. surgical removal and graft replacement. J Thorac Cardiovasc Surg 1976;72:106-108.[Abstract]
- Svensson LG, Crawford ES. Congenital abnormalities of the aorta in adultsIn: Svensson LG, Crawford ES, editors. Cardiovascular and vascular disease of the aorta. Philadelphia: WB Saunders; 1997. pp. 153-174.
- Caus T, Gaubert JY, Monties JR, et al. Right-sided aortic arch. surgical treatment of aneurysm arising from a Kommerell’s diverticulum and extending to the descending thoracic aorta with an aberrant left subclavian artery. Cardiovasc Surg 1994;2:110-113.[Medline]
- Stewart JR, Kincaid OW, Titus JL. Right aortic arch. plain film diagnosis and significance. Am J Roentgenol 1966;97:377-389.[Free Full Text]
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Abstract
Introduction
