Eur J Cardiothorac Surg 2007;32:385-387. doi:10.1016/j.ejcts.2007.04.034
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Retroesophageal right subclavian artery (lusoria) as origin of traumatic aortic rupture
Jens Schneider*,
Reinhard Baier,
Christian Dinges,
Felix Unger
Department of Cardiac Surgery, St. Johann's University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
Received 4 March 2007;
received in revised form 4 April 2007;
accepted 5 April 2007.
* Corresponding author. Address: Universitätsklinik für Herzchirurgie, Müllner Hauptstr. 48, 5020 Salzburg, Austria. Tel.: +43 662 4482 57506; fax: +43 662 4482 3374. (Email: j.schneider{at}salk.at).
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Abstract
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A retroesophageal right subclavian artery (lusoria) is unusual for the surgeon, yet common regarding pathological findings (0.5–2%). Complications arising from it are rare (dysphagia). We report a case of traumatic descending aortic tear originating from a lusoria. The patient had experienced chest trauma due to a skiing accident. CT scan revealed an intramural haematoma of the proximal descending aorta. As a coincidence finding, a retroesophageal right subclavian artery was diagnosed. The patient was first treated conservatively. After an initial period—of stable patient conditions—repeated CT scan revealed a haematoma enlargement and surgery was scheduled: A localized aortic tear was suspected through CT scan, yet no aortic tear or flap was visible. During a two-staged surgical procedure, transpositioning of the lusoria into the right common carotid artery was performed, followed by replacement of the distal aortic arch during a second session using a single-branched Dacron tube graft. The left subclavian artery was then reinserted into the side-branched graft after reuptake of extracorporeal circulation. Extracorporeal circulation was applied via the femoral vessels and circulatory arrest in combination with deep hypothermia. After surgery, the patient was stable, having no signs of neurocognitive dysfunction or dysphagia.
Key Words: Lusoria • Retroesophageal right subclavian artery • Traumatic descending aortic tear • Skiing accident
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1. Introduction
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Encountering a right subclavian artery in cardiac surgery is unusual, yet relatively common regarding retrospective pathological findings (0.5–2% of general population [1,2]). The lusoria originates as the fourth branch of an otherwise normal aortic arch and passes upward to the right behind the oesophagus. It is thought to be one of the causes of dysphagia (dysphagia lusoria). During childhood, a lusoria is rarely symptomatic; however, in adult life, nearly 5% of patients experience symptoms due to tortuosity, atherosclerosis or—rarely—aneurysm formation [3]. In aortic rupture or dissection of the descending aorta, the weakest part of the aorta is the isthmus (loco typico). The mechanism involved in traumatic rupture or dissection is known and can be associated with both thoracic and abdominal compression in combination with a sudden increase in blood pressure [4]. The surgical techniques applied for the treatment of this disease can vary [5].
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2. Case report
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We describe the case of a 47-year-old male (173 cm, 76 kg) with chest trauma and congenital lusoria coincidently found on examination. In this case, we supposed that the lusoria was the origin of a covered localized descending aortic tear.
The patient was admitted to our ER in stable conditions. He had a skiing accident and experienced multiple fractures on both sides of the rib cage, a skull concussion and further minor injuries (Fig. 1
b). Further clinical examination was without pathological findings, except for intermittent dysphagia. Initial CT scan revealed an intramural haematoma with contrast medium leaking out at a point of the distal aortic arch between the left common carotid artery and a retroesophageal right subclavian artery (lusoria) inserting further distal and posterior—a coincidental finding (Fig. 1a). The haematoma (2.6 cm x 1.7 cm) included the origin of the lusoria and also involved the origin of the left subclavian artery. Due to stable patient condition, we decided to treat the patient—at first—conservatively. Control CT scan revealed no further enlargement of the haematoma and again showed no definite signs of a bigger aortic tear. The patient revealed no clinical signs of worsening of his status. On another CT scan after 7 days, the haematoma had increased. A 3D image of the CT scan gave us strong suspicion of definite partial aortic tear. During the interval, the saccular protuberance of the aorta at its medial convexity of the aortic arch had increased to 3.4 cm x 2.4 cm, right at the origin of the lusoria. Again, no definite demarcation of an aortic dissection was visible (Fig. 1c). Surgery was now scheduled, including treatment for dysphagia lusoria.
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Fig. 1. Chest X-ray on admission (a), CT slice showing lusoria and local haematoma (b), 3D CT scan of ascending aorta, aortic arch and descending aorta showing lusoria and haematoma (c), intraoperative finding of lusoria stump (d).
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Due to the worsening of the radiological findings, we decided for a two-staged operative procedure. First, he received a transpositioning of the anomalous inserting retroesophageal right subclavian artery. Herein, the lusoria was distally resected behind the oesophagus and was then inserted into the right common carotid artery by means of an end-to-side anastomosis (Fig. 2a). Then—in a second session—we performed distal aortic arch replacement via an incision in the fourth intercostal space using a left lateral approach. For conduit, a 28 mm Vascutek Gelweave (gelatine impregnated, woven) prosthesis with one 8 mm side arm was chosen. Extracorporeal circulation (ECC) via the femoral vessels and circulatory arrest (37 min, 19.5 °C) was applied. Reinsertion of the left subclavian artery into the single-branched tubular prosthesis was performed after aortic reconstruction with the main-graft and after reuptake of full retrograde flow on ECC. The recurrent laryngeal nerve was carefully retracted by means of a vessel loop. Our belief was proven correct, as during the operation the tear of the descending aorta involved the origin of the left subclavian artery. Hence, antegrade perfusion of the aortic arch would not have been safe (Fig. 2b and c). After successful surgery and uneventful weaning from ECC, the patient was transferred to the ICU and extubated after a further uneventful course 6 h after surgery.
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Fig. 2. Transpositioning of the lusoria to the right common carotid artery (a), intraoperative photo showing aortic dissection involving the origin of left subclavian artery (b), single-branched aortic prosthesis with reattached subclavian artery (c). 3D follow-up CT scan showing single-branched conduit and transpositioned lusoria (d).
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ICU stay was 48 h, ventilation time 6 h and blood loss was 370 ml/24 h. The patient was oriented, coherent and showed no signs of neurocognitive dysfunction. Postoperative X-ray showed no signs of pleural effusion. A follow-up CT scan revealed no further signs of dissection and a functioning of the aortic prosthesis with no signs of leakage or further dissection (Fig. 2d). The patient is alive and doing well after 30 days of follow-up with no signs of dysphagia or hoarseness.
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3. Discussion
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This is a rare case where dysphagia lusoria is coincidental with an aortic tear in loco typico. The question arises if only the rupture should be treated or—in addition—dysphagia lusoria. We decided on a two-staged surgery, not risking recurring dysphagia due to scar tissue formation of the remnants of the lusoria. We could not find a similar case in literature.
In regards to the pathophysiological mechanisms involved, we strongly suspect that an aberrant right subclavian artery (lusoria) may pose a potential risk for the patient: Aortic tear or dissection may occur more likely during deceleration trauma when a lusoria is present. This could be up for further discussion.
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Footnotes
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\#9734; Assistance for this article was made by ‘The Society for the Promotion of Heart Surgery in Salzburg/Gesellschaft zur Förderung der Herzchirurgie in Salzburg’.
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References
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- Attmann T, Brandt M, Müller-Hülsbeck St, Cremer J. Two-stage surgical and endovascular treatment of an aneurysmal aberrant right subclavian (lusoria) artery. Eur J Cardiothorac Surg 2005;27:1125-1127.[Abstract/Free Full Text]
- Van Son JAM, Mierzwa M, Mohr FM. Resection of atherosclerotic aneurysm at origin of aberrant right subclavian artery. Eur J Cardiovasc Surg 1999;16:576-579.[CrossRef]
- Nicolic S, Atanasijevic T, Mihailovic Z, Babic D, Popovic-Loncar T. Mechanisms of aortic blunt rupture in fatally injured front-seat passengers in frontal car collisions: an autopsy study. Am J Forensic Med Pathol 2006;27(4):292-295.[CrossRef][Medline]
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Abstract
1. Introduction
