Contemporary Management of Aberrant Right Subclavian Artery

Abstract

Aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. The purpose of this study was to evaluate contemporary management strategies of patients with ARSA. A single-center retrospective review of patients with ARSA identified by computed tomography imaging from 2009 to 2019 was performed. Demographic data, comorbidities, operative intervention, and outcomes were collected. Aortic and ARSA diameters were measured at 10 different segments. Patients were divided into those who were intervened on and those who were managed expectantly. Linear mixed effect models were used to estimate annual changes in diameter between patients who were just observed and those who were observed and later treated. Thirty patients with ARSA were identified by computed tomography imaging; 55% were female, and the mean age was 54.5 years. Twenty patients underwent operative repair: open surgery in 9 (45%) and hybrid endovascular repair in 11 (55%). The most common indication for repair was Kommerell diverticulum (50%), followed by dysphagia (45%). Concomitant aortic aneurysm disease or dissection was present in 60% of patients. Four of the 10 patients who were initially managed by observation subsequently required intervention. Median diameter of ARSA at its origin was 19.5 mm (interquartile range, 16-23 mm), and the mean cross-sectional aortic diameter at ARSA was 31.8 ± 8.5 mm. The annual growth rate of the origin of ARSA was significantly greater in patients requiring operative intervention compared with those observed (1.65 mm vs 0.16 mm; P = .008). Compared with symptomatic patients, the aortic diameter at the origin of ARSA was significantly larger in asymptomatic patients (24.6 ± 7 mm vs 35.0 ± 7.1 mm; P = .001). However, the diameters of the ascending aorta (33.8 ± 6.6 mm vs 35.6 ± 4.1 mm; P = .44), arch (30.9 ± 6.0 mm vs 31.3 ± 5.2 mm; P = .84), and descending aorta at ARSA (32.5 ± 9.9 mm vs 30.6 ± 4.9 mm; P = .50) were not different between groups. The decision to intervene on ARSA should be individualized on the basis of the presence of symptoms (ie, dysphagia lusoria) as well as anatomic criteria (concomitant aortic aneurysm or dissection, Kommerell diverticulum, or rapid annual growth). Asymptomatic patients with ARSA without concomitant aortic disease can be safely observed with serial surveillance imaging.