Ann Thorac Surg 2007;83:1566-1568
© 2007 The Society of Thoracic Surgeons
How To Do It
Use of the Aberrant Right Subclavian Artery in Complex Aortic Arch Reconstruction
Emile A. Bacha, MDa,*,
Ray Sawaqed, MDb
a Children’s Hospital Boston, Boston, Massachusetts
b Rush University, Oak Lawn, Illinois
Accepted for publication May 16, 2006.
* Address correspondence to Dr Bacha, Harvard Medical School, Children’s Hospital Boston, 300 Longwood Ave, Bader 273, Boston, MA 02115 (Email: emile.bacha{at}cardio.chboston.org).
 |
Abstract
|
|---|
An aberrant right subclavian artery can be used in a variety of ways in complex aortic arch reconstructions. Four patients (3 with interrupted aortic arch and 1 with coarctation) in whom this technique was used are presented.
|
Introduction
|
|---|
Aberrant right subclavian artery (abRSCA) is often associated with interrupted aortic arch (IAA) or aortic coarctation. In coarctation, the abRSCA can originate proximal or distal to the coarctation. Because the abRSCA courses posteriorly behind the esophagus to reach the right thoracic outlet, it can prevent successful mobilization of the descending aorta toward the anterior. This in turn can result in anastomotic tension on the repair, resulting in airway compression or recurrent aortic arch stenosis. We believe that the use of an abRSCA flap in an IAA has not been previously described. We report 4 patients undergoing complex aortic arch repair in which an abRSCA flap was used.
|
Technique
|
|---|
Institutional Board Review was obtained for this study. Between April 2004 and December 2005, 3 patients with IAA and 1 with aortic coarctation and abRSCA underwent repair. All cases were performed under regional low-flow perfusion by cannulation of a 3-mm Goretex graft (W. L. Gore, Flagstaff, AZ) sutured to the right carotid. Deep hypothermic circulatory arrest was not used. All patients had extensive mobilization of the entire aortic arch and descending aorta. The abRSCA was mobilized from behind the esophagus and was ligated and divided leaving a long proximal stump. The ductus was ligated and divided. The opening of the descending aorta was connected to the abRSCA stump, which was then filleted open (Figs 1, 2).
Then an aortic arch repair was carried out using the extra tissue provided by the abRSCA to augment the arch as needed (see as follows).
View larger version (116K):
[in this window]
[in a new window]
|
Fig 2. The ductus arteriosus was ligated, and the filleted aberrant right subclavian artery connected with the descending aortic opening.
|
|
Patients 1 and 2
Two newborns (both 2.7 kg) with IAA type B, ventricular septal defects (VSDs) and abRSCA underwent repair. After transatrial VSD closure (and subaortic conus resection in patient 1), a side biting clamp was placed on the mid descending aorta. The abRSCA stump was filleted open, connecting it with the opening of the descending aorta. An incision was made from the left side of the mid-ascending aorta to the proximal left carotid, and both openings were sutured end to side with running 6-0 Prolene (Figs 1–4).
Both patients recovered with no complications and are asymptomatic with widely patent aortic arches by echocardiogram at 2 and 15 months postoperatively.
View larger version (109K):
[in this window]
[in a new window]
|
Fig 3. The aberrant right subclavian artery flap rotated inferiorly and was sutured to the mid-ascending aorta. The left subclavian artery has been omitted for better clarity.
|
|
Patient 3
A 14-day-old baby boy presented with cardiogenic shock and severe coarctation with aortic arch hypoplasia and abRSCA, as well as a large mid-muscular VSD. After improvement in end-organ function, he underwent intraoperative device closure of the VSD using an 8-mm Amplatzer ductal occluder (AGA Medical Corp, Golden Valley, MN) through a perventricular approach, as well as an extended end-to-end aortic arch repair using the stump of the ligated abRSCA as a reverse flap to enlarge the aortic arch. The AbRSCA was noted to be originating proximal to the coarctation and was larger than the hypoplastic aortic arch itself. The entire procedure was performed on the beating heart, perfusing the coronaries through a cardioplegia cannula connected to a sidearm of the aortic cannula during the aortic arch repair (Figs 5 and 6).
The patient recovered without complications and had no residual pressure gradient across the repair. He is growing well at 20 months postoperatively with a widely patent aortic arch by echocardiogram.
View larger version (65K):
[in this window]
[in a new window]
|
Fig 5. If the aberrant right subclavian artery originates proximal to the obstruction, it can be folded backward to augment a hypoplastic aortic arch (patient 3). Also depicted are the cardiopulmonary bypass set-up with cannulation of the right common carotid for regional low-flow perfusion and concomitant coronary perfusion through a sidearm off the aortic cannula.
|
|
View larger version (68K):
[in this window]
[in a new window]
|
Fig 6. The completed arch repair. The arrow shows the tip of the folded back aberrant right subclavian artery flap that was used to augment the proximal hypoplastic aortic arch. The descending aorta is then sutured end-to-end onto the augmented distal aortic arch.
|
|
Patient 4
A 4-month-old infant with severe DiGeorge syndrome underwent a hybrid stage I (branch pulmonary artery banding and ductal stenting) during the neonatal period for IAA type C with abRSCA, severely hypoplastic aortic annulus and aortic stenosis, and posterior malalignment VSD. Only the right carotid originated from the ascending aorta. The VSD was baffled into both semilunar valves and the arch reconstruction was performed after removal of the ductal stent. Because of a great distance between the ascending and descending aortas, the abRSCA stump was used to create a new greater curvature of the aortic arch, suturing the distal end of the stump to the ascending aorta. The divided main pulmonary artery was then sutured into the opening of the lesser curvature, creating a Damus-Kaye-Stanzel type of anastomosis. A homograft was used to connect the right ventricle to the branch pulmonary arteries. The patient required 3 days of extracorporeal membrane oxygenation support for malignant arrhythmias but was eventually discharged home after 3 weeks in the hospital. He died at home at age 8 months from a sudden fever of unknown origin. An echocardiogram obtained a few days before his death had shown a widely patent arch.
|
Comment
|
|---|
Sirak and colleagues [1] were the first to report on turning down of aortic arch branches for end-to-end anastomosis to the descending aorta in IAA type A. The present series could be described as a "turn up" of the aberrant RSCA flap. The stump of the abRSCA provides a very versatile flap that can be used when situations exist where tension should be avoided or the aortic arch should be augmented. It is autologous tissue, thus providing growth potential. It can be used in many different orientations to augment either the greater curvature or the lesser curvature of the aortic arch. Furthermore, dividing the abRSCA provides better anterior mobility to the descending aorta. There is usually a gap of variable length between both aortic ends, and a tension-free anastomosis is essential for long-term success.
Approximately 1% of patients with aortic coarctation have an associated abRSCA arising either proximal or distal to the coarctation site. The use of an abRSCA flap has been reported in these patients [2–4]. Repair was undertaken through a left thoracotomy and the abRSCA flap used in an antegrade fashion. In our patient with coarctation, the abRSCA flap was used in a reverse fashion to augment the aortic arch in addition to the extended end-to-end anastomosis. Similar principles are used in a reverse left subclavian flap repair for aortic coarctation.
Possible disadvantages include the fact that the subclavian artery is sacrificed. However, the safety and lack of long-term consequences of this maneuver in infantile aortic coarctation repair has been previously documented [5]. In conclusion, the abRSCA flap can be a very useful and versatile technique in complex aortic arch repair with very little drawbacks if any.
|
References
|
|---|
- Sirak HD, Ressallat M, Hosier DM, DeLorimier AA. A new operation for repairing aortic arch atresia in infancyReport of three cases. Circulation 1968;37:II43-II50.[Medline]
- Ko Y, Nakamura Y, Yoshitake M, Inoue T. Aberrant right subclavian artery with preductal coarctation of the aorta Ann Thor Surg 2003;76:927-929.[Abstract/Free Full Text]
- Reid DA, Foster ED, Stubberfield J, Alley RD. Anomalous right subclavian artery arising proximal to a postductal thoracic aortic coarctation Ann Thor Surg 1981;32:85-87.[Abstract/Free Full Text]
- Odell JA, Spilkin S. Anomalous right subclavian artery and coarctation of the aortaSurgical implications and the use of the right subclavian artery as a flap. Br Heart J 1984;5:666-669.
- Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late effects on the left upper limb of subclavian flap aortoplasty J Thorac Cardiovasc Surg 1983;85:678-681.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
S. Westaby, A. Agarwal, J. Kadlec, and F. Flynn
Repair of type B interrupted aortic arch using aberrant right subclavian artery
Interact CardioVasc Thorac Surg,
September 1, 2009;
9(3):
528 - 529.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
