Ann Thorac Surg 2007;83:e3-e5
© 2007 The Society of Thoracic Surgeons
How To Do It
Total Arch Replacement for a Distal Aortic Arch Aneurysm With Right Aortic Arch
Keiko Kiokawa, MDa,*,
Kazutomo Goh, MDb,
Nobuyuki Akasaka, MDa,
Nobuyoshi Azuma, MDa,
Masashi Inaba, MDa,
Tadahiro Sasajima, MD
a First Department Surgery, Asahikawa Medical University, Asahikawa-city, Hokkaido, Japan
b Emergent Medicine, Asahikawa Medical University, Asahikawa-city, Hokkaido, Japan
Accepted for publication October 16, 2006.
* Address correspondence to Dr Kiyokawa, 2-1-1-1 Midorigaoka Higashi, Asahikawa-city, Hokkaido, 078-8510 Japan. (Email: kiyokawa{at}asahikawa-med.ac.jp).
 |
Abstract
|
|---|
Right-sided aortic arch accompanied by an aberrant origin of the left subclavian artery is rare and seen in 0.05%
0.1% of the population. A 73-year-old woman with this anomaly was admitted to our institution because of the enlargement of the distal aortic arch aneurysm. She also had mild dysphagia. The size of the aneurysm was 70 mm in diameter and she underwent total arch replacement using selective cerebral perfusion through a median sternotomy. Additional right thoracotomy was not required and four cervical vessels were reconstructed. The postoperative course was uneventful. This case report shows median sternotomy alone may provide sufficient access for this pathology.
|
Introduction
|
|---|
Right-sided aortic arch and an aberrant origin of the left subclavian artery is an uncommon anatomy. In general, its surgical intervention is required when there are symptoms caused by obstruction of the trachea or esophagus or when there is an enlargement of Kommerell’s diverticulum. In these cases, a right or left thoracotomy is usually used to approach the lesion. However with atherosclerotic change of the aorta, the surgical intervention is more complicated. We experienced a case of a distal aortic arch aneurysm with this anomaly. Total arch replacement was performed in a good surgical field through the median sternotomy alone. The purpose of this report is to show our experience and the surgical management.
|
Technique
|
|---|
A 73-year-old woman who was diagnosed as having distal arch aneurysm in the setting of right aortic arch and aberrant left subclavian artery with Kommerell’s diverticulum was admitted to our hospital because of an enlargement of the distal aortic arch aneurysm. She had the history of hypertension. She also had mild dysphagia, but there was no progression of the symptom. On preoperative chest roentgenogram the presence of a right aortic knob and the right descending aorta was noticed. Echocardiography showed no intracardiac lesion. A chest computed tomographic scan with contrast showed a large distal arch aneurysm (Fig 1). The size was 70 mm in diameter. The first branch of the aorta was the left common carotid artery followed by the right common carotid artery and the right subclavian artery. The left subclavian artery arose from the so-called Kommerell’s diverticulum on the left wall of the descending aorta and passed behind the esophagus (Fig 2). However there was no enlargement of the esophagus proximal to the diverticulum. Surgical intervention was planned to avoid a rupture of the distal arch aneurysm. With the patient in the supine position, with the right arm hung over the head in case of the need for an additional right thoracotomy, the chest was opened through a median sternotomy. Cardiopulmonary bypass was established using an arterial return cannula in the ascending aorta, the left axillary artery, and the right femoral artery, and a venous drainage cannula was used in the right atrium. Selective antegrade cerebral perfusion was performed to the left common carotid artery, the right common carotid artery, and the right subclavian artery. A longitudinal incision on the posterior pericardium between the ascending aorta and the superior vena cava made it possible to expose the descending aorta, despite the acute angulation of the right aortic arch. The ascending portion of the left subclavian artery was exposed behind the left common carotid artery and was then divided. The proximal end of the left subclavian artery was ligated, and a 10-mm woven Dacron graft (Gelweave, Vascutek, Sulzer Medica, UK) was anastomosed to the distal end to prepare for later anastomosis. The patient was cooled down to 25°C. The aorta was cross clamped first on the ascending aorta, and then on the descending aorta distal to the diverticulum through the posterior pericardial incision between the ascending aorta and the superior vena cava. The aorta was incised between the clamps. Open distal anastomosis was achieved with a Dacron graft with four branches in a good operative field. The level of the distal anastomosis was just above the first intercostal artery. Then proximal anastomosis between the ascending aorta and the graft was performed in the usual fashion. The aorta was de-clamped and each cerebral branch was reconstructed individually. The 10-mm graft on the left subclavian artery was anastomosed to the first branch of the graft (Figs 3–5).
Weaning from cardiopulmonary bypass was smooth. The postoperative course was uneventful, and the dysphagia symptoms disappeared.
View larger version (167K):
[in this window]
[in a new window]
|
Fig 1. Preoperative chest contrast computed tomographic scan. A large distal arch aneurysm with a maximal diameter of 70 mm and four aortic branches, left common carotid artery, right common carotid artery, right subclavian artery, and left subclavian artery were noticed.
|
|
View larger version (25K):
[in this window]
[in a new window]
|
Fig 3. The drawing shows the operative procedure. The 10 mm anterior branch was anastomosed to the right subclavian artery.
|
|
View larger version (161K):
[in this window]
[in a new window]
|
Fig 5. Postoperative chest computed tomographic scan with contrast showed four aortic branches reconstructed successfully. The aneurysm was resected and replaced with a prosthetic graft.
|
|
|
Comment
|
|---|
Management of the right aortic arch, aberrant left subclavian artery, and Kommerell’s diverticulum may be different in young patients without atherosclerosis than in the old patients with atherosclerosis. A symptomatic patient with trachea or esophagus compressed by the diverticulum needs early surgical intervention, and in such a case a right or left thoracotomy is used to achieve surgery to release the compression [1, 2]. A surgical approach to the older patient with atherosclerosis depends on the concomitant lesion, such as dissection or aneurysm [3–8]. In our case there was a distal arch aneurysm and total arch replacement was required, so we selected the median sternotomy. We believed that it was possible to expose the distal anastomotic site on the descending aorta, which would be distal to the Kommerell’s diverticulum through the median sternotomy, because the computed tomographic image showed that the aneurysmal change ended above the level of the right pulmonary artery. In most literature, a right thoracotomy is the approach of choice to perform total arch replacement for this anatomy [7, 8]. However, a median sternotomy alone may make it easier to achieve selective cerebral perfusion and to deal with the unexpected situation. In this case, because we reconstructed the left subclavian artery in the left side of esophagus and trachea, the possible compression caused by Kommerell’s diverticulum was successfully released.
Recently, hybrid endovascular techniques such as open surgery with stent grafting have been reported as being successfully applied to the aortic arch aneurysm. However, in this case the acute angulation of the right aortic arch may make it difficult to exclude the aneurysm using a commercially available stent-graft system.
With our technique, the median sternotomy provided easy access both to the descending aorta and the branches of the aortic arch, less invasive incision on the chest, and more ideal reconstruction of the left subclavian artery [3, 7].
|
References
|
|---|
- Jung JY, Almond CH, Saab SB. Surgical repair of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum J Thorac Cardiovasc Surg 1978;75:237-243.[Abstract]
- Morel V, Corbineau H, Lecoz A. Two cases of "asthma" revealing a diverticulum of Kommerell Respiration 2002;69:456-460.[Medline]
- Caus T, Gaubert JY, Monties JR. Right-sided aortic arch: surgical treatment of an 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]
- Nobaki K, Irie Y, Hata I. Kommerell’s diverticular rupture complicated by aberrant leftsubclavian artery and rignt aortic arch successfully treated surgically Jpn J Thorac Cardiovasc Surg 2005;53:255-258.[Medline]
- Mossad E, Farid I, Youssef G. Diverticulum of Kommerell: a review of a series and a report of a case with tracheal deviation compromising single lung ventilation Anesht Analg 2002;94:1462-1464.
- Satomi Y, Shigeyuki A, Hideki O. Total arch replacement for right aortic arch with Kommerell diverticulm and aberrant left subclavian Artery Thorac Surg 2003;l56(5):403-405.
- Cina CS, Arena GO. Kommerell’s diverticulum and aneurysmal right-sided aortic arch: a case report and review of the literature J Vasc Surg 2000;32:1208-1214.[Medline]
- Tsukube T, Ataka K, Sakata M. surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery Ann Thorac Surg 2001;71:1710-1711.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
D. Hori, M. Tanaka, A. Yamaguchi, and H. Adachi
Type A Aortic Dissection, Right-Sided Aortic Arch, and Thoracic Aortic Aneurysm
Asian Cardiovasc Thorac Ann,
December 1, 2009;
17(6):
640 - 642.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
