Aberrant Right Subclavian Artery Aneurysm Research Articles

Endovascular Management for an Aberrant Right Subclavian Aneurysm

Introduction: Aberrant right subclavian artery (ARSA) aneurysm repair is usually performed surgically. Case Presentation: We report the case of an endovascular exclusion of ARSA aneurysm using a degressive covered endograft via axillary access. This technique can avoid classical complications of an open surgical repair and the complexity of hybrid techniques, especially in patients of advanced age with multiple comorbidities.

Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery.

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.

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

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

Dysphagia Lusoria: A Rare Entity and Underrecognized Cause of Dysphagia

Abstract Management of dysphagia lusoria (DL), dysphagia caused by esophageal compression by an aberrant right subclavian artery (ARSA), is a clinical challenge. Sixty percent of patients with ARSA develop an aneurysm in the aberrant artery, which increases the risk of developing worsening dysphagia, tracheal compression, aortic dissections, and aneurysmal ruptures. Surgical management of ARSA has been studied, but no definitive standards have been established. As a result, most patients elect for surgery only when compressive symptoms become too severe. We present the case of a 68-year-old male found to have worsening dysphagia from an enlarging ARSA aneurysm. A bilateral carotid-subclavian bypass with embolization of both subclavian arteries and aortic endograft placement was performed. Despite imaging showing successful bypass of the aneurysm, the patient’s compressive symptoms worsened. The patient had a prolonged postoperative course that was complicated by pneumonia and tracheal compression, requiring stent placement. On postoperative day 45, the patient went into cardiac arrest and expired. Postmortem examination revealed an ARSA aneurysm measuring 7.8 × 4.5 × 4.3 cm. All grafts and embolization plugs were in place, without evidence of failure or migration. The aneurysmal sac contained a firm, well-organized clot, occupying 80% of the lumen. Diffuse ulcerative atherosclerotic disease was noted in the aorta. The lungs had gross and histologic findings consistent with pneumonia. Final cause of death was determined to be acute pneumonia with mass effect of the ARSA aneurysm as a contributing factor. Although the cause of the aneurysmal clot formation could not be identified, it raised the question of whether the degree of aortic atherosclerosis and aneurysmal size should be considered while developing indications for surgery. With the increased detection of ARSA, this case suggests the degree of aortic atherosclerosis and size of the aneurysm should be considered in the establishment of surgical guidelines.

Aberrant right subclavian artery re-routing for hybrid repair of proximal descending aortic aneurysm

BackgroundAn aberrant right subclavian artery (ARSA) is a relatively prevalent vascular anomaly. What is the most appropriate treatment for thoracic aortic aneurysm combined a non-aneurysmal change ARSA?Case presentationA 52-year-old man was admitted to our institute due to a history of chronic cough, dysphagia and an abnormal chest radiographic finding. Because of his progressive symptoms and large fusiform thoracic aneurysm, we performed the hybrid repair for simultaneous relief of an ARSA causing dysphagia and thoracic aneurysm.ConclusionIn case without aneurysm of ARSA, especially in conjunction with approximate thoracic aneurysm, our approach is suitable because the revascularization using the right carotid to subclavian artery re-routing prior to endograft deployment is justified in order to preserve circulation of posterior brain, spinal cord, internal mammary artery and upper limb and to prevent large retrograde type II endoleaks, as well as simplicity and durability.

Results of aberrant right subclavian artery aneurysm repair

The objective of this multicenter registry was to review current treatments and late results of repair of aneurysm of aberrant right subclavian artery (AARSA). All consecutive AARSA repairs from 2006 to 2013 in seven centers were reviewed. End points were 30-day and late mortality, reintervention rate, and AARSA-related death. Twenty-one AARSA repairs were included (57% men; mean age, 67 years); 3 ruptures (14%) required emergent treatment; 12 (57%) were symptomatic for dysphagia (33%), dysphonia (24%), or pain (19%). Eight cases (38%) presented with thoracic aortic aneurysm, two with intramural hematoma, and one with acute type B aortic dissection. Mean AARSA diameter was 4.2 cm; a single bicarotid common trunk was present in 38% of cases. The majority of patients underwent hybrid intervention (n = 15; 71%) consisting of single (n = 2) or bilateral (n = 12) subclavian to carotid transposition or bypass or ascending aorta to subclavian bypass (n = 1) plus thoracic endovascular aortic repair (TEVAR); 19% of cases underwent open repair and 9% simple TEVAR with AARSA overstenting. Perioperative death occurred in two patients (9%): in one case after TEVAR in ruptured AARSA, requiring secondary sternotomy and aortic banding; and in an elective case due to multiorgan failure after a hybrid procedure. Median follow-up was 30 (interquartile range, 15-46) months. The Kaplan-Meier estimate of survival at 36 months was 90% (standard error, 0.64). Late AARSA-related death in one case was due to AARSA-esophageal fistula presenting with continuing backflow from distal AARSA and previous TEVAR. At computed tomography controls, one type I endoleak and one type II endoleak were detected; the latter required reintervention by aneurysm wrapping and ligature of collaterals. AARSA-related death was more frequent after TEVAR, a procedure reserved for ruptures, compared with elective open or hybrid repair. Hybrid repair is the preferred therapeutic option for patients presenting with AARSA. Midterm results show high rates of clinical success with low risk of reintervention. Simple endografting presents high risk of related death; these findings underline the importance of achieving complete sealing to avoid treatment failures.

A Case Report of Surgical Treatment of Symptomatic Aberrant Right Subclavian Artery Aneurysm (ARSA) at Bangkok Hospital Phuket, Thailand

Aberrant right subclavian artery (ARSA), also called arteria lusoria, is one of the most common intrathoracic arterial anomalies. Although most of the patients are asymptomatic, the retroesophageal and retrotracheal course of the lusorian artery&nbsp

Embolization of an Aberrant Right Subclavian Artery Aneurysm with Amplatzer Vascular Plug without Bypass

Aberrant right subclavian artery (ARSA) aneurysms are rare, but the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. Open surgical repair of ARSA aneurysms usually requires thoracotomy and aortic grafting, which can be contraindicated in high-risk patients with multiple comorbidities. Endovascular repair of ARSA aneurysms has been reported, with or without adjunctive surgical bypass. We report a case of an 80-year-old woman resenting with an asymptomatic 4 cm ARSA aneurysm who underwent a completely endovascular treatment of the aneurysm using an Amplatzer vascular plug II (St. Jude Medical Inc., St. Paul, MN).

Hybrid Endovascular Treatment of an Anomalous Right Subclavian Artery Dissection in a Patient With Marfan Syndrome

We report the case of a 26-year-old female patient with Marfan syndrome and an aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum. The patient presented with spontaneous acute dissection of the ARSA that showed fusiform dilation to 4 cm in diameter. Definitive treatment was performed using a two-stage hybrid endovascular technique, including extrathoracic bilateral upper extremity bypass and thoracic endovascular aortic repair with debranching of the right and left subclavian arteries. This was followed by coil and plug embolization to exclude the dissection and prevent subsequent endoleak.

Staged Coil Embolisation for the Management of Persistent Aneurysmal Right Subclavian Artery

A 70-year-old patient, who had previously undergone open surgical repair of an aneurysmal aberrant right subclavian artery (ARSA), presented with recurrent symptoms and reperfusion of the aneurysm at the site of proximal ligation. This was successfully treated by a staged endovascular procedure.

Aneurysm of the Aberrant Right Subclavian Artery: Surgical and Hybrid Repair of Two Cases in a Single Center

The aberrant right subclavian artery (ARSA) aneurysm is rare; however, the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. In this report, we have described two cases of this anomaly. In the first case, a 62-year-old male patient presented with a symptomatic aneurysm of ARSA (maximum diameter of 4 cm) causing chest pain with dyspnea during moderate physical effort. Surgical treatment was performed with aneurysmal exclusion and direct anastomosis of the two heads of the subclavian artery. In the second case, a 72-year-old male patient presented with a symptomatic aneurysm (maximum diameter of 5.1 cm) of ARSA causing dysphagia and dysphonia. In this case, a one-stage hybrid treatment was performed: a bilateral carotid-subclavian bypass was associated with intentional occlusion of both subclavian arteries (by plug positioning) during thoracic endovascular stent-grafting procedures. In both cases, the peri/postoperative course was uneventful and the technical results in our series were excellent at long-term follow-up. Surgical treatment can be safely performed in patients with low operative risk or whenever endovascular technique is not suitable. The ARSA aneurysm, with appropriate anatomy, can be successfully treated by hybrid treatment (combined surgical andendovascular approach). We reckon that this minimally invasive technique helps avoid thoracotomy and could be the treatment of choice in high-risk patients.

Endovascular Treatment of Acute Type B Dissection and Kommerell’s Diverticulum

A 59-year-old man presented with severe hypertension and resistant interscapular pain. Transesophageal echocardiography and computed tomographic angiogram demonstrated acute type B dissection associated with aberrant right subclavian artery with 3.5 cm Kommerell's diverticulum. Open repair was deemed to be high risk to elevate perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical therapy because of resistant thoracic pain. We did not observe intraoperative or perioperative mortality and right arm ischemia or symptomatic subclavian steal.

Management Options for Kommerell's Diverticulum

An aberrant right subclavian artery (ARSA) arising from a left-sided aortic arch (LAA) is an uncommon aortic arch anomaly. Aneurysms of ARSA arising from different degrees of Kommerell's diverticulum may modify surgical approach. We describe a safe technique for the surgical management of ARSA aneurysm in a 67-year-old gentleman. We performed exclusion of an ARSA aneurysm using left heart bypass, with concomitant R axillary to RSCA bypass. This obviated the need for any major procedure such as an aortic arch replacement.

Surgical Treatment of Aberrant Right Subclavian Artery (Arteria Lusoria) Aneurysm Using Three Different Methods

Here we report our surgical experiences with aberrant right subclavian artery (ARSA) aneurysm in 8 patients. Eight patients underwent surgical treatment for ARSA aneurysm between March 1994 and June 2005. The age of these patients ranged from 20 to 75 years. The mean size of the ARSA aneurysm was 3.3 cm, ranging from 2 to 5 cm. The ARSA aneurysm was completely resected through a left posterolateral thoracotomy after reconstruction of the right subclavian artery through the supraclavicular approach in 4 patients (group 1). The ARSA aneurysm was excluded through a left posterolateral thoracotomy without revascularization of the right subclavian artery in 2 patients (group 2). The distal site of the ARSA aneurysm was closed followed by revascularization through a median sternotomy, and the ARSA aneurysm was left as a blind sack in 2 patients (group 3). None of the patients in group 1 or 3 had any postoperative complications. In group 2, 1 had a steal syndrome caused by the exclusion of the ARSA aneurysm, and the other died of sepsis 2 months after the operation. Complete anatomical repair of the ARSA aneurysm could be performed through the combination of the supraclavicular approach and the left posterolateral thoracotomy, with excellent results. Exclusion of the ARSA aneurysm without revascularization resulted in a suboptimal outcome. Surgical results of simple closure of the ARSA followed by revascularization were uneventful, but the ARSA aneurysm was left as a blind sack.

Percutaneous Treatment of Aberrant Right Subclavian Artery Aneurysm with Use of the Amplatzer Septal Occluder

Aberrant right subclavian artery (ARSA) aneurysms are rare but carry a high risk of rupture and require early elective treatment. The present report describes a 60-year-old man with an asymptomatic ARSA aneurysm for whom surgical treatment would have been associated with a high degree of risk. The ARSA aneurysm was occluded with use of Amplatzer septal occluders, which avoided high-risk surgery and preserved antegrade flow into the left common carotid, subclavian, and vertebral arteries and perfusion of the right upper extremity through an induced right subclavian steal. The eventual need for bypass surgery for perfusion of the right upper extremity was assessed after the procedure.

Two-stage surgical and endovascular treatment of an aneurysmal aberrant right subclavian (Lusoria) artery

We report a case of a 75-year-old male patient with an asymptomatic aneurysm of an aberrant right subclavian artery (ARSA). Timely elective therapy of this entity is indicated due to the high risk of rupture. Because of the patient's reduced physical state, we performed an interdisciplinary endovascular aortic stent-grafting for the exclusion of the ARSA aneurysm. However, the proximal landing zone for the thoracic stent had to be chosen proximal to the origin of the left subclavian artery. Thus, 2 days before the endovascular procedure, a left-sided carotido-subclavian bypass was accomplished. The peri- and postoperative course was uneventful. The technical results in our patient were excellent, no leakage was visible so far.