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Surgical management of aneurysms at the origin of an aberrant right subclavian artery
Surgical management of aneurysms at the origin of an aberrant right subclavian artery An aneurysmal origin of an aberrant right subclavian artery should preferably be closed with a prosthetic patch inserted with the aid of cardiopulmonary bypass with deep hypothermia and circulatory arrest Three patients were operated on: a transaortic approach was used in two and a transaneurysmal approach in one. This technique aUows a single-stage surgical correction of this rare anomaly through a median sternotomy and obviates the need for hazardous and difficult side clamping of the aorta. (J THORAC CARDIOVASC 8URG 1994;107:1469-71)
Michel W. Verkroost, MD, Ruben P. Hamerlijnck, MD, PhD, and Freddy E. Vermeulen, MD,
Nieuwegein, The Netherlands
Several types of congenital vascular anomalies produce partial or total encirclement of the trachea and esophagus. These vascular rings, slings, and other abnormalities of the aortic arch rather frequently lead to dysphagia or dyspnea with stridor, or both. A left-sided aortic arch with an aberrant right subclavian artery, as first described by Hunauld, 1 is the most common aortic arch anomaly, occurring in approximately 0.5% of the population.i The second most common aortic arch anomaly is caused by persistence of both the right (posterior) and left (anterior) fourth branchial arches. The majority of patients with this anomaly have anatomic continuity but luminal atresia of the anterior arch. Aneurysms in the course of an aberrant right subclavian artery are not frequently encountered.' Between 1956 and 1990 only 39 cases were reported.v 5 An aneurysm at the very origin of an aberrant right subclavian artery is rare, with only four cases reported until now."? In the St. Antonius Hospital, in a 6-year period, we have operated on three patients with this latter combination of anomalies. To our belief repair of this rare entity neces-
From theDepartment ofCardiothoracic Surgery, St. Antonius Hospital,Nieuwegein, The Netherlands. Received for publication April 24, 1991. Accepted forpublication Oct. 5, 1993. Address for reprints: Michel W.Verkroost, MD,St. Antonius Hospital,P.O.Box 2500, 3430 EM, Nieuwegein, The Netherlands. Copyright © 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00
+0
12/1/52223
sitates a specific surgical technique of patch closure with the aid of deep hypothermia and circulatory arrest. Methods and results In our three patients a mass was visiblein the upper part of the mediastinum on the chest x-ray films. Computed tomographic scans of the mediastinum and intraarterial angiograms revealed a large aneurysm at the origin of an aberrant right subclavianartery in two patients (both 68 years of age) (Fig. 1) and a double aortic arch with atresia of the anterior arch and a large aneurysm originating from the dorsal aortic arch in the third patient (47 years of age). The first two patients had dysphagia, and the third had progressive swellingof the head and neck because the aneurysm was compressingthe superior vena cava. In all patients the operation was done through a median sternotomy.The incisionwas extended into the right supraclavicular region.Cardiopulmonary bypass was established by cannulation of the right common femoral artery and the right atrium. After the patient was cooled by extracorporeal circulation to a nasopharyngealtemperature of 120 C and a rectal temperature of 240 C, circulatory arrest was induced. The ascending aorta and arch vessels were clamped. In the two patients in whom the aneurysm was at the origin of the aberrant right subclavian artery, a longitudinalincisionwas made in the aortic arch starting at the right common carotid artery and extending to just distal to the originof the aberrant right subclavianartery, which is the last major branch of the thoracic descending aorta. The presence of true aneurysms was confirmed. The origin of the aneurysm was subsequently closed with a gelatin-sealed (Gelseal, Vascutek, Inchinnan, Renfrewshire,U. K.) prosthetic patch with 4-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, N .1.). The originswere4 and 3 ern in diameter. The continuity with the distal right subclavian artery was restored afterward with an 8 mm Gelseal interposition graft that was proximally anastomosed to the ascending aorta in one patient (Fig. 2) and to the right common carotid artery in the other
1469
I 470
The Journal of Thorac ic and Cardiovascular Surgery June 1994
Verkroost, Hamerlijnck, Vermeulen
~, -
, N- S? / 11 :
Fig. 1. Preoperative oblique digital substraction angiogram of the aortic arch. Arrows indicate the aneurysm (measuring 40 mm) at the origin of the arch .
Fig. 2. Postoperative digital substraction angiogram showing the interposition graft (arrow) between the ascending aorta and the distal right subclavian artery. patient (Fig . 3). In the patient with aneurysmal origin of the right subclavian artery from the dorsal aortic arch, the origin of the aneurysm was closed during a circulatory arrest of 35 minutes through the aneurysm. A 4 by 3 em Gelseal prosthetic patch was inserted with running 4-0 Prolene sutures. The circulation to the distal right subclavian artery was restored with an 8 mm Gelseal interposition graft proximally anastomosed to the ascending aorta . The right vertebral artery was reimplanted into
Fig. 3. Postoperative digital substraction angiogram of the interposition graft (arrow) between the right common carotid artery and the distal right subclavian artery.
Fig. 4. Postoperative intraarterial angiogram showing the interposition graft (small arrows) between the ascending aorta and distal right subclavian artery. Note the reimplantation of the right vertebral artery (large arrow). the prosthesis, and the origin of the right internal mammary artery was oversewn. In none of the patients was the aneurysm excised. The postoperative course was uneventful in the first two
The Journal of Thoracic and Cardiovascular Surgery Volume 107, Number 6
patients.The third patient had diffuseencephalopathythat had almost completely resolved at dischargeon the twenty-first day after the operation. All patients had excellent pulsations and equal blood pressures in both the brachial and radial arteries. Postoperative angiograms in the third patient showed a good result (Fig. 4). In none of the patients did we encounter detrimental sequelae resulting from retention of the aneurysm.
Discussion In children the aberrant right subclavian artery is soft and pliable, whereas by late adolescence the development of atherosclerotic rigidity, tortuosity, and dilation of its origin may result in compression of the esophagus or superior vena cava, as occurred in our three patients.l'' The surgical approach in four patients with an aneurysmal origin of an aberrant right subclavian artery so far described in the literature consisted of the following: a left thoracotomy in two patients (one in combination with a right supraclavicular incision), a right thoracotomy in one patient,6-8 and in the fourth patient a technique similar to the one that we described, namely, median sternotomy with a transaortic approach to the aneurysm with deep hypothermia and circulatory arrest." In the fourth patient the operation was combined with myocardial revascularization. We used a one-stage approach through a median sternotomy with deep hypothermia and circulatory arrest to facilitate a good exposure of the orifices of the aneurysm, either transaortically or through the aneurysm. Such an approach also obviates the need for difficult and hazardous clamping of the aorta around the base of the aneurysm, which is likely to be calcified in these generally older patients. In addition, the (peri)aneurysmal aortic tissue is frequently fragile. Extension of the incision into the right supraclavicular region adequately exposes the distal right subclavian artery and facilitates restoration of its circulation by insertion of an interposition graft that can be anastomosed to the ascending aorta or the right common carotid artery. Profound hypothermia with circulatory arrest is the most common method of cerebral protection during operations on the aortic arch. Alternatively, as we cur-
Verkroost, Hamerlijnck, Vermeulen
I 47 I
rently favor, selective cold cerebral perfusion by cannulation of one or both carotid arteries with profound corporeal hypothermia and circulatory arrest can be performed. The latter technique may be safer in older patients or in complex arch operations with expected long arrest times. Another alternative for cerebral protection with cold cerebroplegia was recently described by Bachet and associates. 1I REFERENCES 1. Hunauld. Examen de quelques parties d'un signe. Hist Acad R Sci 1735;2:516-23. 2. Klinkhamer AC. Esophagographyin anomaliesof the aortic arch system. Baltimore: Williams & Wilkins, 1969: I 630,64-5.
3. McCollum CH, De Gama AD, Noon GP, DeBakey ME. Aneurysm of the subclavian artery. J Cardiovasc Surg 1979;20: 159-64.
4. Jauch K-W, Riel K-A, Lauterjung L, Berger H. Aneurysmen der Arteria Lusoria. Falldarstellung und literaturiibersicht. Chirurgie 1988;59:418-24. 5. Stone WM, Brewster DC, Moncure AC, et ai. Aberrant right subclavianartery: varied presentations and management options. J Vase Surg 1990;11 :812-7. 6. McCallen AM, Schaff B.Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-3. 7. Hunter JA, Dye WS, Javid H, Najafi H, Julian Oc. Arteriosclerotic aneurysmof anomalous right subclavianartery. J THORAC CARDIOVASC SURG 1970;59:754-8. 8. Campbell CF. Repair of an aneurysm of an aberrant retroesophageal right subclavian artery arising from Kommerell's diverticulum. J THoRAc CARDIOVASC SURG 1971;62:330-4.
9. BaiIlot RG, Beven EG, Cosgrove DM. Aneurysm of an aberrant right subclavian artery: repair using circulatory arrest. Cleve Clin Q 1984;51: 173-5. 10. van Son JA, Vincent JG, van Oort A, Lacquet LK. Translocation of aberrant right subclavian artery in dysphagia lusoria in children through a right thoracotomy. Thorac Cardiovasc Surg 1989;37:52-4. 11. Bachet J, Guilmet D, Goudot B, et ai. Cold cerebroplegia: a newtechniqueof cerebral protectionduring operationson the transverse aortic arch. J THORAC CARDIOVASC SURG 1991;102:85-94.
Michel W. Verkroost, MD, Ruben P. Hamerlijnck, MD, PhD, and Freddy E. Vermeulen, MD,
Nieuwegein, The Netherlands
Several types of congenital vascular anomalies produce partial or total encirclement of the trachea and esophagus. These vascular rings, slings, and other abnormalities of the aortic arch rather frequently lead to dysphagia or dyspnea with stridor, or both. A left-sided aortic arch with an aberrant right subclavian artery, as first described by Hunauld, 1 is the most common aortic arch anomaly, occurring in approximately 0.5% of the population.i The second most common aortic arch anomaly is caused by persistence of both the right (posterior) and left (anterior) fourth branchial arches. The majority of patients with this anomaly have anatomic continuity but luminal atresia of the anterior arch. Aneurysms in the course of an aberrant right subclavian artery are not frequently encountered.' Between 1956 and 1990 only 39 cases were reported.v 5 An aneurysm at the very origin of an aberrant right subclavian artery is rare, with only four cases reported until now."? In the St. Antonius Hospital, in a 6-year period, we have operated on three patients with this latter combination of anomalies. To our belief repair of this rare entity neces-
From theDepartment ofCardiothoracic Surgery, St. Antonius Hospital,Nieuwegein, The Netherlands. Received for publication April 24, 1991. Accepted forpublication Oct. 5, 1993. Address for reprints: Michel W.Verkroost, MD,St. Antonius Hospital,P.O.Box 2500, 3430 EM, Nieuwegein, The Netherlands. Copyright © 1994 by Mosby-Year Book, Inc. 0022-5223/94 $3.00
+0
12/1/52223
sitates a specific surgical technique of patch closure with the aid of deep hypothermia and circulatory arrest. Methods and results In our three patients a mass was visiblein the upper part of the mediastinum on the chest x-ray films. Computed tomographic scans of the mediastinum and intraarterial angiograms revealed a large aneurysm at the origin of an aberrant right subclavianartery in two patients (both 68 years of age) (Fig. 1) and a double aortic arch with atresia of the anterior arch and a large aneurysm originating from the dorsal aortic arch in the third patient (47 years of age). The first two patients had dysphagia, and the third had progressive swellingof the head and neck because the aneurysm was compressingthe superior vena cava. In all patients the operation was done through a median sternotomy.The incisionwas extended into the right supraclavicular region.Cardiopulmonary bypass was established by cannulation of the right common femoral artery and the right atrium. After the patient was cooled by extracorporeal circulation to a nasopharyngealtemperature of 120 C and a rectal temperature of 240 C, circulatory arrest was induced. The ascending aorta and arch vessels were clamped. In the two patients in whom the aneurysm was at the origin of the aberrant right subclavian artery, a longitudinalincisionwas made in the aortic arch starting at the right common carotid artery and extending to just distal to the originof the aberrant right subclavianartery, which is the last major branch of the thoracic descending aorta. The presence of true aneurysms was confirmed. The origin of the aneurysm was subsequently closed with a gelatin-sealed (Gelseal, Vascutek, Inchinnan, Renfrewshire,U. K.) prosthetic patch with 4-0 polypropylene sutures (Prolene; Ethicon, Inc., Somerville, N .1.). The originswere4 and 3 ern in diameter. The continuity with the distal right subclavian artery was restored afterward with an 8 mm Gelseal interposition graft that was proximally anastomosed to the ascending aorta in one patient (Fig. 2) and to the right common carotid artery in the other
1469
I 470
The Journal of Thorac ic and Cardiovascular Surgery June 1994
Verkroost, Hamerlijnck, Vermeulen
~, -
, N- S? / 11 :
Fig. 1. Preoperative oblique digital substraction angiogram of the aortic arch. Arrows indicate the aneurysm (measuring 40 mm) at the origin of the arch .
Fig. 2. Postoperative digital substraction angiogram showing the interposition graft (arrow) between the ascending aorta and the distal right subclavian artery. patient (Fig . 3). In the patient with aneurysmal origin of the right subclavian artery from the dorsal aortic arch, the origin of the aneurysm was closed during a circulatory arrest of 35 minutes through the aneurysm. A 4 by 3 em Gelseal prosthetic patch was inserted with running 4-0 Prolene sutures. The circulation to the distal right subclavian artery was restored with an 8 mm Gelseal interposition graft proximally anastomosed to the ascending aorta . The right vertebral artery was reimplanted into
Fig. 3. Postoperative digital substraction angiogram of the interposition graft (arrow) between the right common carotid artery and the distal right subclavian artery.
Fig. 4. Postoperative intraarterial angiogram showing the interposition graft (small arrows) between the ascending aorta and distal right subclavian artery. Note the reimplantation of the right vertebral artery (large arrow). the prosthesis, and the origin of the right internal mammary artery was oversewn. In none of the patients was the aneurysm excised. The postoperative course was uneventful in the first two
The Journal of Thoracic and Cardiovascular Surgery Volume 107, Number 6
patients.The third patient had diffuseencephalopathythat had almost completely resolved at dischargeon the twenty-first day after the operation. All patients had excellent pulsations and equal blood pressures in both the brachial and radial arteries. Postoperative angiograms in the third patient showed a good result (Fig. 4). In none of the patients did we encounter detrimental sequelae resulting from retention of the aneurysm.
Discussion In children the aberrant right subclavian artery is soft and pliable, whereas by late adolescence the development of atherosclerotic rigidity, tortuosity, and dilation of its origin may result in compression of the esophagus or superior vena cava, as occurred in our three patients.l'' The surgical approach in four patients with an aneurysmal origin of an aberrant right subclavian artery so far described in the literature consisted of the following: a left thoracotomy in two patients (one in combination with a right supraclavicular incision), a right thoracotomy in one patient,6-8 and in the fourth patient a technique similar to the one that we described, namely, median sternotomy with a transaortic approach to the aneurysm with deep hypothermia and circulatory arrest." In the fourth patient the operation was combined with myocardial revascularization. We used a one-stage approach through a median sternotomy with deep hypothermia and circulatory arrest to facilitate a good exposure of the orifices of the aneurysm, either transaortically or through the aneurysm. Such an approach also obviates the need for difficult and hazardous clamping of the aorta around the base of the aneurysm, which is likely to be calcified in these generally older patients. In addition, the (peri)aneurysmal aortic tissue is frequently fragile. Extension of the incision into the right supraclavicular region adequately exposes the distal right subclavian artery and facilitates restoration of its circulation by insertion of an interposition graft that can be anastomosed to the ascending aorta or the right common carotid artery. Profound hypothermia with circulatory arrest is the most common method of cerebral protection during operations on the aortic arch. Alternatively, as we cur-
Verkroost, Hamerlijnck, Vermeulen
I 47 I
rently favor, selective cold cerebral perfusion by cannulation of one or both carotid arteries with profound corporeal hypothermia and circulatory arrest can be performed. The latter technique may be safer in older patients or in complex arch operations with expected long arrest times. Another alternative for cerebral protection with cold cerebroplegia was recently described by Bachet and associates. 1I REFERENCES 1. Hunauld. Examen de quelques parties d'un signe. Hist Acad R Sci 1735;2:516-23. 2. Klinkhamer AC. Esophagographyin anomaliesof the aortic arch system. Baltimore: Williams & Wilkins, 1969: I 630,64-5.
3. McCollum CH, De Gama AD, Noon GP, DeBakey ME. Aneurysm of the subclavian artery. J Cardiovasc Surg 1979;20: 159-64.
4. Jauch K-W, Riel K-A, Lauterjung L, Berger H. Aneurysmen der Arteria Lusoria. Falldarstellung und literaturiibersicht. Chirurgie 1988;59:418-24. 5. Stone WM, Brewster DC, Moncure AC, et ai. Aberrant right subclavianartery: varied presentations and management options. J Vase Surg 1990;11 :812-7. 6. McCallen AM, Schaff B.Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-3. 7. Hunter JA, Dye WS, Javid H, Najafi H, Julian Oc. Arteriosclerotic aneurysmof anomalous right subclavianartery. J THORAC CARDIOVASC SURG 1970;59:754-8. 8. Campbell CF. Repair of an aneurysm of an aberrant retroesophageal right subclavian artery arising from Kommerell's diverticulum. J THoRAc CARDIOVASC SURG 1971;62:330-4.
9. BaiIlot RG, Beven EG, Cosgrove DM. Aneurysm of an aberrant right subclavian artery: repair using circulatory arrest. Cleve Clin Q 1984;51: 173-5. 10. van Son JA, Vincent JG, van Oort A, Lacquet LK. Translocation of aberrant right subclavian artery in dysphagia lusoria in children through a right thoracotomy. Thorac Cardiovasc Surg 1989;37:52-4. 11. Bachet J, Guilmet D, Goudot B, et ai. Cold cerebroplegia: a newtechniqueof cerebral protectionduring operationson the transverse aortic arch. J THORAC CARDIOVASC SURG 1991;102:85-94.