Ann Thorac Surg 2008;85:1074-1076. doi:10.1016/j.athoracsur.2007.09.032
© 2008 The Society of Thoracic Surgeons
Case Reports
Endovascular Repair of a Right-Sided Descending Thoracic Aortic Aneurysm With a Right-Sided Aortic Arch and Aberrant Left Subclavian Artery
Joseph J. Naoum, MDa,b,
Jennifer L. Parenti, RNa,c,
Scott A. LeMaire, MDa,c,*,
Joseph S. Coselli, MDa,c
a The Texas Heart Institute at St. Luke’s Episcopal Hospital, and Division of Vascular and Endovascular Surgery, Baylor College of Medicine, Houston, Texas
b Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
c Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
Accepted for publication September 17, 2007.
* Address correspondence to Dr LeMaire, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030 (Email: slemaire{at}bcm.edu).
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Abstract
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Aneurysms involving a right-sided aortic arch and a right-sided descending thoracic aorta with an aberrant origin of the left subclavian artery are rare. We describe the successful surgical repair of this vascular anomaly by the combined use of a left carotid to subclavian artery bypass followed by endovascular stent-graft placement to exclude the aortic aneurysm. We also review the literature associated with this particular anatomic presentation.
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Introduction
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A right-sided aortic arch is a rare anomaly that occurs in 0.05% of the population when it is associated with an aberrant subclavian artery. The majority of cases cause no symptoms. The diagnosis is usually made incidentally during chest roentgenography or computed tomography performed for other reasons. Aneurysms of a right-sided descending thoracic aorta (DTA) are even rarer; only a handful of cases have been documented.
A 58-year-old man with depression, anxiety disorder, and a 60-pack-year smoking history reported chest pain of several months’ duration; he had no upper respiratory complaints, nor did he report dysphagia or weight loss. During his workup, a chest roentgenogram revealed a right-sided aortic arch and an anteriorly displaced trachea. A computed tomographic scan of the chest and abdomen revealed a fusiform aneurysm of the DTA. The aneurysm was 6.5 cm in maximal diameter and involved a large Kommerell’s diverticulum that included an aberrant retroesophageal left subclavian artery. The aneurysm originated in the distal aortic arch and extended to the lower DTA.
The procedure was performed under general endotracheal anesthesia and full hemodynamic monitoring after placement of a spinal drain. First, aortography was performed to delineate the arch anatomy (Fig 1); this was followed by a left carotid to subclavian artery bypass and ligation of the proximal left subclavian artery (Fig 2). Then the right femoral artery was exposed through an oblique incision and cannulated with a 24-French delivery Gore Introducer sheath (W. L. Gore & Associates Inc, Flagstaff, AZ). Multiple GORE TAG Thoracic Endoprosthesis stent grafts (W. L. Gore & Associates Inc) were deployed (Fig 3). The proximal and distal landing zones were between 2 and 2.5 cm in length. A completion angiogram showed that normal circulation had been restored through both carotid arteries and the right subclavian artery. The angiogram also showed a patent left carotid subclavian bypass, occlusion of the origin of the left subclavian artery without evidence of any type of endoleak, and successful exclusion of the aneurysm (Fig 4).
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Fig 1. (A) Drawings and (B, C, D) arteriograms of the patient’s right-sided aortic arch, right-sided descending thoracic aortic aneurysm, and aberrant left subclavian artery. (B) Right anterior oblique (RAO) projection showing the right and left common carotid arteries arising from a common trunk. The right vertebral artery is dominant. (C) An RAO projection showing a left subclavian artery arising from a Kommerell’s diverticulum, which is particularly evident in the inset (arrow). The left vertebral artery is small. (D) A left anterior oblique view demonstrates the landing zone target immediately distal to where the right subclavian artery originates from the aorta. (a = artery; L = left; R = right.)
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Fig 2. Arteriogram showing a patent left carotid to subclavian artery bypass. No flow is visible in the proximal left subclavian artery, confirming its proximal ligation. (L = left.)
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Fig 3. Illustration of the completed repair, including left carotid to subclavian bypass and endovascular exclusion of the aortic aneurysm.
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After surgery, the patient was hoarse because of left vocal cord paralysis that probably resulted from nerve injury during the left carotid to subclavian bypass and that was treated with thyroplasty. He had no other postoperative complications and was discharged home on postoperative day 8. His follow-up computed tomographic scans have shown no evidence of endoleak, including the most recent scan performed 17 months after the operation.
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Comment
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The few reported cases of surgical treatment of right-sided arch aneurysms illustrate the rarity of this condition and the technical challenges associated with each patient’s particular anatomy. Anatomic findings unique to each patient include the pattern of the aortic arch vessels, the location of the descending aorta (right or left), the relation of the aorta to any anomalous originating vessels, the relation of the trachea and the esophagus to the aorta and arch vasculature, and the associated cardiac anomalies. A right-sided aortic arch can also be associated with a complete vascular ring, depending on the location of the origins of the left subclavian artery and ligamentum arteriosum. Cooley and associates [1] reported the repair of an extensive fusiform aneurysm of a right-sided cervical arch and a ventricular septal defect in a 39-year-old woman. Caus and colleagues [2] reported the successful repair of a 12-cm aneurysm that developed from a Kommerell’s diverticulum at the origin of an aberrant retroesophageal left subclavian artery in a 44-year-old man with a right-sided arch and DTA. The repair involved graft replacement of the upper third of the DTA through a right thoracotomy incision. In one of two cases reported by Robinson and colleagues [3], a 40-year-old patient had a right-sided aortic arch with an aberrant left subclavian artery arising from a Kommerell’s diverticulum in the descending portion of the aorta. This patient was diagnosed with a distal aortic arch aneurysm extending into the DTA and underwent a left common carotid to left subclavian artery bypass, followed by aneurysm repair. The distal aortic arch and descending aorta were replaced through a right thoracotomy while the patient was under circulatory arrest. The Kommerell’s diverticulum was resected, and the aberrant left subclavian artery stump was oversewn. The second patient, a 58-year-old man with a 6-cm aneurysm in the posterior aorta, also had a right-sided arch, as well as an anomalous left-sided innominate artery arising from the ascending aorta, whose two branches were adherent to the descending aorta. Repair was performed through a left thoracotomy and involved a combination of right subclavian artery perfusion and hypothermic circulatory arrest. Tsukube and colleagues [4], who treated 3 patients with a right-sided aortic arch and saccular aneurysmal enlargement of a Kommerell’s diverticulum, performed a median sternotomy on the first patient but found that a right thoracotomy was also required, leading the authors to repair the remaining two patients’ aneurysms through a right thoracotomy. Each patient underwent either deep hypothermia with circulatory arrest or partial cardiopulmonary bypass. In all cases, the aberrant left subclavian artery was reimplanted with an interposition tube graft. Oberwalder and colleagues [5] also reported the use of a right anterolateral thoracotomy for the repair of an 8-cm aneurysm originating distal to a right-sided aortic arch. The repair was performed while the patient was on cardiopulmonary bypass.
Endovascular treatment of right-sided aortic arch aneurysms is appealing because it avoids a thoracotomy or median sternotomy, and it obviates the need for circulatory arrest, which is commonly required with the conventional approach. Okada and associates [6] demonstrated the feasibility of endovascular repair in a 76-year-old man with an aneurysm that involved a right-sided aortic arch and a left-sided descending aorta. The aneurysm was excluded with a handmade stent-graft composed of a modified Gianturco stainless-steel Z-stent (Cook Inc, Bloomington, IN) and thin-walled Dacron (DuPont, Wilmington, DE). The current report confirms that endovascular thoracic stent-grafting is a viable and safe alternative to open surgical repair in these rare and complex cases.
Surgeons should consider both clinical and anatomic factors when selecting endovascular treatment and planning the repair in patients with right-sided aortic lesions. For example, endovascular repair would not be effective in patients presenting with compressive symptoms caused by a complete vascular ring. Meticulous preoperative imaging with three-dimensional reconstructions of the aorta can improve diagnostic accuracy and facilitate surgical planning. When the stent-graft will cover the origin of an aberrant left subclavian artery (or the associated Kommerell’s diverticulum), proximal ligation or coil embolization of the artery will prevent a type II endoleak, which can occur as a result of perfusion of the aneurysmal sac by retrograde blood flow from the subclavian artery. Subclavian revascularization should be considered in cases in which the left subclavian artery inflow is interrupted.
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Acknowledgments
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The authors thank Scott A. Weldon, MA, CMI, for creating medical illustrations and Stephen N. Palmer, PhD, ELS, for providing editorial assistance.
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References
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- Cooley DA, Mullins CE, Gooch JB. Aneurysm of right-sided cervical arch: surgical removal and graft replacement J Thorac Cardiovasc Surg 1976;72:106-108.[Abstract]
- Caus T, Gaubert JY, Monties JR, et al. 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]
- Robinson BL, Nadolny EM, Entrup MH, Svensson LG. Management of right-sided aortic arch aneurysms Ann Thorac Surg 2001;72:1764-1765.[Abstract/Free Full Text]
- Tsukube T, Ataka K, Sakata M, Wakita N, Okita Y. 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]
- Oberwalder PJ, Bergmann P, Tillich M, Rigler B. Aneurysm of a right-sided aortic arch and right descending aorta: three-dimensional volume rendering of multislice computed tomographic aortography facilitates surgical planning and management J Thorac Cardiovasc Surg 2005;129:953-954.[Free Full Text]
- Okada K, Sueda T, Orihashi K, Watari M, Naito A. Endovascular stent-graft repair for thoracic aortic aneurysm associated with right-sided aortic arch J Thorac Cardiovasc Surg 2001;122:185-186.[Free Full Text]
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Abstract
Introduction
