Single-stage Total Endovascular Therapy for an Aberrant Right Subclavian Artery Aneurysm

Abstract

Introduction: An aberrant right subclavian artery (ARSA) is one of the most common congenital vascular anomalies of the aortic arch. ARSA aneurysms are rare, and few cases of ARSA aneurysm in patients undergoing total endovascular therapy have been reported. Methods: A 34-year-old woman was referred to our hospital after a chest X-ray abnormality was pointed out during medical checkup. Contrast-enhanced computed tomography (CT) showed a left-sided aortic arch with a saccular ARSA aneurysm (Image 1). The maximum size of the aneurysm was 33 mm. The diameter of the proximal neck was 11 - 14 mm, the distance from the origin of the ARSA to the aneurysm was 20 mm, the length of the aneurysm was 50 mm, the distance from the aneurysm to the right vertebral artery (RVA) was 5 mm and the diameter of the right axillary artery (RAxA) was 6 - 7 mm. The diameters of the bilateral vertebral arteries were almost equal. Single-stage total endovascular therapy with preservation of the RVA using a surgeon-modified fenestrated stent-graft was planned. The operation was performed under general anesthesia. The RAxA was exposed, a 6-F sheath was percutaneously inserted from the right femoral artery and a 9-F sheath was directly inserted from the RAxA. A stiff guidewire was passed into the descending aorta from the 9-F sheath of the RAxA through the ARSA aneurysm and the 9-F sheath was replaced by a 12-F sheath. An PXL161007J EXCLUDER® iliac extender (W. L. Gore & Associates, Flagstaff, AZ, USA) was inserted into the 12-F sheath and then was deployed from the proximal landing zone to inside the ARSA aneurysm. Then, an ETLW1610C93EJ ENDURANT Ⅱ® limb (Medtronic PLC, Minneapolis, MN, USA) was unsheathed on a clean table and a 5 mm fenestration was made at the graft between the 5th and 6th stents. A coil (as a radiopaque marker) was sutured to the graft at the margin of the fenestration, and the surgeon-modified stent-graft was resheathed in the original sheath of the ENDURANT Ⅱ®. The resheathed ENDURANT Ⅱ® was inserted from the RAxA, the orifice of the RVA was identified by angiography, and was deployed at the position of the radiopaque marker in the RVA orifice. Results: Completion angiography and contrast-enhanced CT on postoperative day 4 demonstrated the patency of the stent-graft, RVA and RAxA, with no evidence of endoleak (Image 2). The postoperative course was uneventful, and the patient was discharged on postoperative day 6. Twelve months later, follow-up CT showed that the maximum diameter of the ARSA aneurysm had decreased from 33 mm to 27 mm. Conclusion: When an ARSA aneurysm is anatomically suitable, single-stage total endovascular therapy with preservation of the RVA by a surgeon-modified fenestrated stent-graft is feasible and effective. However, as the long-term outcome is unknown, careful follow-up is needed. Disclosure: Nothing to disclose