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Eur J Cardiothorac Surg 1999;16:246-248
© 1999 Elsevier Science NL

Case report

Two-stage repair of a combined aneurysm of the descending aorta and the aberrant right subclavian artery

Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany

Corresponding author. Department of Cardiovascular Surgery, Christian-Albrechts-University, Amold-Heller-Strasse 7, D-24105 Kiel, Germany. Tel.: +49-431-5974400; fax: +49-431-5974402
e-mail: aboening{at}kielheart.uni-kiel.de

	Abstract

Top Abstract 1. Case report 2. Comment References

 
In cases of combined aneurysms of the descending aorta and the aberrant right subclavian artery a common surgical strategy has not been clearly elaborated. In this report the case of a 76-year-old male patient with this rare combination of aneurysms is presented. The surgical strategy consisted of a two-stage approach for repairing both aneurysms maintaining the perfusion of the right subclavian and vertebral artery, finally providing an excellent postoperative result even in a patient of this advanced age.

Key Words: Aberrant right subclavian artery • Aneurysm • Surgical repair

	1. Case report

Top Abstract 1. Case report 2. Comment References

 
An aberrant subclavian artery (aSA) is a rare anomaly of the supraaortic arteries in approximately 0.5% of normal individuals [1]. Even more rare is the development of an aneurysm of the aSA, especially when combined with an aneurysm of the descending aorta. For these combined aneurysms a common surgical strategy has not been clearly elaborated: applied approaches differ between one stage repair of the descending aortic aneurysm and more complex reconstructions requiring hypothermic circulatory arrest.

As an unexpected finding, in a 76-year-old male patient suffering from pneumonia the chest X-rays showed a widened upper mediastinum besides typical pneumonic infiltrations. Consecutive computed tomography revealed a 6.5x5 cm measuring aneurysm of the proximal descending aorta and, in continuity, a 3.5 cm in diameter measuring aneurysm of an aSA extending into the posterior mediastinum (Fig. 1). Regarding his aneurysmatic disease, the patient was asymptomatic: there were no signs of dysphagia, shortness of breath, peripheral embolization or concomitant occlusive disease. Routine preoperative diagnostic excluded a coronary or valvular heart disease and significant carotid artery disease.

View larger version (111K): [in this window] [in a new window]   Fig. 1. Preoperative computed tomography of the chest revealing the aneurysm of the proximal descending aorta extending into an aneurysm of the aberrant subclavian artery.

In the second step 2 weeks later, after an uneventful reconvalescence the repair of the aortic aneurysm followed approaching through a posterolateral thoracotomy entering the fourth intercostal space. Installing non-pulsatile bypass perfusion from the left atrium to the distal descending normal aorta a routine dacron prosthetic graft replacement (24 mm aortic tube prosthesis; Uni Graft KDV, Braun Melsungen AG, Germany) of the aorta was performed. In addition the aSA was ligated distal to its aneurysm.

Perioperatively, no major complications occured and adequate perfusion of the central nervous system, the left arm and the descending aorta could be assessed. Related to the extension of the aneurysm, left laryngeal recurrent nerve palsy was unavoidable and along with speech therapy a marked improvement of the patient's hoarseness could be achieved. Intercurrent psychiatric disorders spontaneously normalized until discharge on the 20th postoperative day. Non-invasively measured blood pressures in the left and right arm were 145/90 and 140/90 mm Hg preoperatively and 90/60 and 120/75 mm Hg postoperatively. Postoperative carotid doppler flow measurement and control CT scanning could assess adequate results for both repairs (see also Fig. 2, schematic drawing).

View larger version (51K): [in this window] [in a new window]   Fig. 2. Schematic drawing of the situs after two-stage repair of the aSA and descending aortic aneurysms by interposition of a dacron graft and a carotido-subclavian bypass.

	2. Comment

Top Abstract 1. Case report 2. Comment References

According to Kieffer et al. [1], a thoracic approach appears clearly required in such cases. However, resection of the aneurysmal part of the aSA and reinsertion into the aorta through a lateral thoracotomy seemed not reasonable in this case, where the aneurysmal aSA extended widely into the posterior right mediastinum. Therefore, we chose a two stage approach for repairing both aneurysms maintaining the perfusion of the right subclavian artery. A complete repair of both aneurysms through a median sternotomy as reported by von Segesser [3] and Verkroost et al. [4] appeared also not realistic in our patient because of the distal extension of the aneurysm (8 cm) into the descending aorta.

The concept of an artificial proximal aSA stenosis to prevent intercurrent early graft closure of the carotido-subclavian bypass due to non-restrictive competitive flow before doing the second step seemed to be highly effective. Using a 6-0 polypropylene suture this stenosis should be correctable by percutaneous transluminal angioplasty later on to improve the inflow into the right vertebral artery, if needed. In our patient, however, postoperative blood pressure was sufficiently high allowing for an unrestricted use of the arm, so that a further improvement of blood flow appeared not required.

Applying a two stage repair with initial reconstruction of the aSA perfusion, circulatory arrest techniques as mentioned by Kieffer could be avoided. Moreover, the proximal location of the descending aortic aneurysm allowed for implantation of a left atrio-descending aortic bypass delivering antegrade flow to the abdominal organs. Thus, potential embolization from atherosclerotic lesions by femoral arterial cannulation could be avoided also.

In agreement with Stoney [5] and Esposito et al. [6], we consider the two stage approach the best therapeutic modality for this group of patients.

	References

Top Abstract 1. Case report 2. Comment References

 

1. Kieffer E., Bahnini A., Jkoskas F. Aberrant subclavian artery: surgical treatment in thirty-three adult patients. J Vasc Surg 1994;19:10-11.
2. Jauch W., Riel K.A., Lauterjung L., Berger H. Aneurysmen der Arteria lusoria Chirurg 1988;59:418-424.
3. Von Segesser L., Faidutti B. Symptomatic aberrant retro-esophageal subclavian artery: considerations about the surgical approach, management and results. Thorac Cardiovasc Surgeon 1984;32:307-310.[Medline]
4. Verkroost M.W., Hamerlijnck R.P., Vermeulen F.E. Surgical management of aneurysms at the origin of an aberrant right subclavian artery. J Thorac Cardiovasc Surg 1994;107:1469-1471.[Abstract/Free Full Text]
5. Stoney W.S., Alford W.C., Burrus G.R., Thomas C.S. Aberrant right subclavian artery aneurysm. Ann Thorac Surg 1975;19:460-467.[Abstract]
6. Esposito R.A., Khalil I., Galloway A.C., Spencer F.C. Surgical treatment for aneurysm of aberrant subclavian artery based on a case report and a review of the literature. J Thorac Cardiovasc Surg 1988;95:888-891.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Andreas Boening Christoph Dresler Axel Haverich Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boening, A. Articles by Cremer, J. Search for Related Content PubMed PubMed Citation Articles by Boening, A. Articles by Cremer, J.