Aberrant Subclavian Artery Research Articles

Unraveling the enigma of an aberrant subclavian artery (arteria lusoria)

Our understanding of the aberrant subclavian artery (ASA), also known as arteria lusoria, which is derived from lusus naturae (meaning freak of nature), from which dysphagia lusoria is also named, remains incomplete and poor. Various issues need to be clarified including the origin (congenital vs degenerative) of Kommerell’s diverticulum (KD), the reason for varied anatomic course of the ASA in relation to the esophagus, and the pathophysiology of dysphagia. Even the term KD is not well defined and is often used synonymously—but erroneously—with an ASA aneurysm.

Left Nonrecurrent Laryngeal Nerve with Situs Inversus Totalis.

The recurrent laryngeal nerve (RLN), a branch of the vagus nerve, supplies the motor and sensation function of the larynx. Generally, RLN detours around the right subclavian artery on the right side and the aortic arch on the left side. In a rare anatomical variant, called nonrecurrent laryngeal nerve (NRLN), the nerve takes an aberrant path rather than descending into the thorax as usual. First reported in 1823, NRLN is a rare anomaly arising almost exclusively on the right side, reported in 0.3–0.8% of people, and associated with vascular anomalies of embryonic aortic arch development. The atypical vascular pattern of aberrant subclavian artery (arteria lusoria) running behind the trachea and esophagus allows the vagus nerve to pass freely, which then directly branches out as NRLN at the level of the larynx. On the other hand, cases of left NRLN, only reported in 0.004% of people, are all accompanied by significant pathologies such as situs inversus totalis with opposite vascular pattern of left aberrant subclavian artery. This rare anatomical variation is clinically important, as NLRN is a major risk factor for iatrogenic injury during thyroidectomy, parathyroidectomy, and other invasive procedures in the head and neck region.

Hemiclamshell Approach Not Minimally Invasive!

In this issue of The Annals of Thoracic Surgery, Salem and colleagues,1 from Frankfurt, Germany, have described an interesting approach to a symptomatic 31-year-old patient with a right aortic arch, aberrant left subclavian artery, and a moderate sized Kommerell diverticulum. The approach was through an upper ministernotomy connected to a left-sided hemiclamshell incision. They used a vascular stapler to occlude the base of the diverticulum, resected the diverticulum, and transferred the left subclavian artery to the left common carotid artery.

Thoracic Endovascular Aortic Repair for Aberrant Subclavian Artery and Stanford Type B Aortic Intramural Hematoma.

ObjectivesTo evaluate the in-hospital and later outcomes of thoracic endovascular aortic repair (TEVAR) for type B intramural hematoma (TBIMH) combined with an aberrant subclavian artery (aSCA).MethodsIn the period from January 2014 to December 2020, 12 patients diagnosed with TBIMH combined with aSCA and treated by TEVAR were enrolled in this retrospective cohort study, including 11 patients with the aberrant right subclavian artery (ARSA) and 1 with an aberrant left subclavian artery (ALSA). A handmade fenestrated stent-graft or chimney stent or hybrid repair was performed when the proximal landing zone was not enough.ResultsThe mean age of all the patients was 59.2 ± 7.6 years, and 66.7% of patients were men. There were 4 patients with Kommerell's diverticulum (KD). The procedures in all 12 patients were technically successful. There was one case each of postoperative delirium, renal impairment, and type IV endoleak after TEVAR. During follow-up, 1 patient died of acute pancreatitis 7 months after TEVAR. The overall survival at 1, 3, and 5 years for the patients was 90.9, 90.9, and 90.9%, respectively. KD was excluded in 2 patients, and the handmade fenestrated stent-graft was applied in the other 2 patients to preserve the blood flow of the aSCA. No neurological complications developed and no progression of KD was observed during the follow-up.ConclusionThoracic endovascular aortic repair for patients with aSCA and TBIMH is promising. When KD was combined, we could exclude KD or preserve the blood flow of aSCA with regular follow-up for the diverticulum according to the size of the KD.

Dual esophageal compression secondary to two vascular abnormalities.

We report the case of a 65-year-old male with hypertension, diabetes and hypercholesterolemia, who presented due to pyrosis and regurgitation. A CT scan incidentally identified esophageal compression at two sites because of vascular abnormalities, which was asymptomatic. The proximal compression was due to a Kommerell's diverticulum (Fig. 1) and the distal one due to aortic tortuosity (Fig. 2). Esophageal manometry revealed a distal obstructive pattern of mechanical origin, which was consistent with the observed aortic kink. The esophagogram (Fig. 3) showed a proximal filling defect and a bend in the distal third.

Management of Aberrant Subclavian Artery Disease in the Contemporary Era: Is It Time to Find a Common Treatment For a Rare Disorder?

In recent years, renewed attention has been given to aberrant subclavian artery disease (ASAD), and Konstantinou et al. report outcomes of its surgical treatment over 30 years (1990 – 2020; 314 studies; 732 patients).1 After separation of patients into two groups: Group A (open or hybrid surgery through sternotomy/thoracotomy; n = 453 patients) and Group B (endovascular or hybrid treatment without chest access; n = 279 patients), pooled early mortality rates were 1.62% and 1.96%, respectively, while pooled symptomatic relief rates were 99.52% and 95.79%, respectively.

Repair of Kommerell's Diverticulum and Aberrant Subclavian Arteries: Classification of the Five Groups in Declining Frequency and Their Operative Approaches

Repair of Kommerell's Diverticulum and Aberrant Subclavian Arteries: Classification of the Five Groups in Declining Frequency and Their Operative Approaches

A rare anomalous origin of the right vertebral artery from the right aortic arch with the left aberrant subclavian artery arising from kommerell's diverticulum

Right-sided aortic arch (RAA) with left aberrant subclavian artery (LASA) is a rare vascular variant due to the failure in regression process during embryologic development of the aortic arch. The prevalence of it ranges from 0.04% to 0.1% in radiology series. We report the case of a 44-year-old female shown to have the presence of a RAA with LASA arising from the Kommerell's diverticulum, and also in association with an aberrant aortic origin of the right vertebral artery using computed tomography angiography. Considering the diameter of the diverticulum <5 cm and the absence of severe external esophageal or tracheal compression, thoracic surgery was not indicated and it was decided to keep the patient under clinical follow-up at regular intervals. Based upon this present case and literature review, the knowledge of this anomalous anatomy and its embryologic basis appear to be important for diagnostic endovascular interventions and planning thoracic surgery.

Extended Replacement of the Aortic Arch and Descending Aorta

Objective: Reporting our experience of total arch replacement through the left thoracotomy. Patients: From October 1999 to April 2021, 69 patients, aging 62.4 ± 13.7 years (26-84), underwent extensive aortic arch replacement from the ascending aorta, aortic arch, and to the descending aorta. The aneurysm consisted with 2 acute type A dissection, 35 chronic type A dissection, 1 acute type B dissection, 11 chronic type B dissection, 12 non-dissection plus chronic type B dissection, 11 nondissection with mega-aorta, and 4 Kommerell diverticulum. Various segments of aorta were replaced prior to extensive surgery, such as aortic root 7, ascending aorta 25, arch 3, descending aorta 1, thoracoabdominal aorta 1, and AAA 3. Two had ruptured aneurysm, 2 had intraoperative aortic dissection, 3 had graft infection, 2 had tracheotomy, and 1 had cardiac arrest. Methods: Forty-five patients had left posterolateral thoracotomy, 8 had anterolateral left thoracotomy plus partial midsternotomy, 2 had midsternotomy plus left thoracotomy, 2 had right posterolateral thoracotomy, I had Clamshell bilateral thoracotomy, and 13 had left thoracotomy + retroperitoneal approach. All patients underwent total arch and descending aorta replacement. In addition, three had aortic root replacement, 3 had ST junction plication, on had AVR, 12 had reconstruction of the segmental arteries, 13 had replacement of the thoracoabdominal aorta, and 2 had esophagus resection. Sixty-five had antegrade cerebral perfusion and 4 had deep hypothermic circulatory arrest with retrograde cerebral perfusion. Results: There were 4 early deaths (5.8 %). The causes of deaths were preoperative cardiac arrest due to aneurysm rupture, low cardiac output, acute myocardial infarction, and head injury. Conclusion: Extended replacement of the aortic arch and the descending aorta might be useful for the selected patients. Objective: Reporting our experience of total arch replacement through the left thoracotomy. Patients: From October 1999 to April 2021, 69 patients, aging 62.4 ± 13.7 years (26-84), underwent extensive aortic arch replacement from the ascending aorta, aortic arch, and to the descending aorta. The aneurysm consisted with 2 acute type A dissection, 35 chronic type A dissection, 1 acute type B dissection, 11 chronic type B dissection, 12 non-dissection plus chronic type B dissection, 11 nondissection with mega-aorta, and 4 Kommerell diverticulum. Various segments of aorta were replaced prior to extensive surgery, such as aortic root 7, ascending aorta 25, arch 3, descending aorta 1, thoracoabdominal aorta 1, and AAA 3. Two had ruptured aneurysm, 2 had intraoperative aortic dissection, 3 had graft infection, 2 had tracheotomy, and 1 had cardiac arrest. Methods: Forty-five patients had left posterolateral thoracotomy, 8 had anterolateral left thoracotomy plus partial midsternotomy, 2 had midsternotomy plus left thoracotomy, 2 had right posterolateral thoracotomy, I had Clamshell bilateral thoracotomy, and 13 had left thoracotomy + retroperitoneal approach. All patients underwent total arch and descending aorta replacement. In addition, three had aortic root replacement, 3 had ST junction plication, on had AVR, 12 had reconstruction of the segmental arteries, 13 had replacement of the thoracoabdominal aorta, and 2 had esophagus resection. Sixty-five had antegrade cerebral perfusion and 4 had deep hypothermic circulatory arrest with retrograde cerebral perfusion. Results: There were 4 early deaths (5.8 %). The causes of deaths were preoperative cardiac arrest due to aneurysm rupture, low cardiac output, acute myocardial infarction, and head injury. Conclusion: Extended replacement of the aortic arch and the descending aorta might be useful for the selected patients.

A lung cancer revealing a right aortic arch with a Kommerell diverticulum: A case report

A lung cancer revealing a right aortic arch with a Kommerell diverticulum: A case report

Dysphagia, looking further than the usual suspects, a case report

Background: Vascular ring is a rare diagnosis in adults as the majority is diagnosed in symptomatic infants or young children. Only a few cases are documented in the literature of dysphagia in adults caused by a vascular ring. It is not uncommon for an adult diagnosed with vascular rings to have asthma in his medical history. Case Presentation: A 61-year-old woman presented with dysphagia with a medical history of slight asthma and left hemithyroidectomy. After extensive workup, it was determined to be the result of a right-sided aortic arch with a left-sided arteriosum ligament, a left aberrant subclavian artery with Kommerell&amp;apos;s diverticulum, and a ventral left common carotid artery. Conclusion: A right-sided aorta with a left-sided arteriosum ligament is a vascular ring and should be recognized as such. Although rare in adults, one should be triggered to think of a vascular ring in patients with dysphagia, especially with mild asthma and reflux complaints.

Interrupted aortic arch without differential cyanosis due to aberrant subclavian artery

Interrupted aortic arch without differential cyanosis due to aberrant subclavian artery

Incidence of Aberrant Right Subclavian Artery in General Population

Objective: The existence of an anomalous right subclavian artery is the most significant aortic arch defect. Dysphagia, wheezing, stridor, and other symptoms may occur if this vessel pressures the neighbouring structures. The goal of this study is to find out how common ARSA is based on CT scans of the thorax and neck (plain and contrast).&#x0D; Method: Between January 1st and December 31st, 2020, 1122 patients had CT Thorax/neck scans, and the data were evaluated. The origin of the ARSA, the vessel's path, and the Kommerell diverticulum were all assessed. We looked at the literature to see how important ARSA is in clinical practise.&#x0D; Results: ARSA was found in eight of 1122 patients. All of the ARSAs in these eight individuals began at the posterior part of the aortic arch and travelled via the retroesophageal path to the thoracic outlet. All eight ARSA were found in the front part of the thoracic vertebral bodies, from the first to the fourth.&#x0D; Conclusion: Other clinical symptoms such as dysphagia, dyspnea, retrosternal discomfort, cough, and weight loss must be differentiated from compression of surrounding tissues by an abnormal right subclavian artery.

Central Partial Bypass Management Technique for Distal Arch Surgery.

Circulatory arrest and left heart bypass are the most common approaches to manage perfusion during distal arch surgery. We report a novel perfusion technique utilized in the treatment of aneurysmal Komerrell's diverticulum (KD) and aberrant subclavian artery (ASA) that allows for a reliable conduct of perfusion. From 2016 to 2020, 12 adult patients with aneurysmal KD and ASA underwent repair of distal arch through lateral thoracotomy ipsilateral to the arch side using central partial bypass. Once the patients were fully heparinized the lower thoracic aorta and the right atrium were cannulated. The cannulas were connected to the cardiopulmonary bypass (CPB) circuit with an oxygenator. Partial bypass was initiated. Ventilation via anesthesia was continued as the mode of gas exchange to the upper body while the CPB circuit provided gas exchange to the lower body. In all patients, CPB was initiated allowing the patient to maintain a mean arterial pressure >60 mmHg in the femoral artery and a mean arterial pressure (MAP) >80 mmHg in the radial artery to allow adequate native ejection into the proximal circulation. The venous line was partially occluded to control the radial pressure. The aorta was cross clamped proximal and distal to the KD to isolate the aorta to be replaced. KD was excised in all patients having performed contralateral subclavian to carotid transposition previously. Once the aorta was reconstructed, clamps were released and the patients were weaned off CPB. All were extubated on the same day and there was no early mortality.

Contemporary management and natural history of aberrant right subclavian artery

ObjectiveAn aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. A paucity of reported studies is available regarding the treatment of these patients. The purpose of the present study was to evaluate the contemporary management strategies and natural history of ARSA in these patients. MethodsA single-center retrospective review of patients with a diagnosis of ARSA from 2009 to 2019 was performed. Computed tomography scans were analyzed, and the aortic and ARSA diameters were measured at 10 different segments. The demographic data, comorbidities, and operative interventions were collected. The patients were categorized into those who had undergone intervention and those who had undergone expectant management. Linear mixed effect models were used to estimate the annual ARSA diameter changes. ResultsA total of 30 patients with ARSA were identified, 17 (57%) of whom were women. The average age for the cohort was 54.5 ± 14.6 years. Of the 30 patients, 20 (67%) had undergone operative repair at presentation and 10 (33%) were initially observed. The most common presenting symptom was dysphagia (30%). Of the 10 patients who had been initially treated expectantly, 4 had subsequently required intervention. Of the 24 operative interventions, 13 (54%) were hybrid procedures involving right carotid–subclavian bypass or transposition and thoracic endovascular aortic repair. The mean diameter of ARSA at its origin was 20.4 ± 5.7 mm, and the mean cross-sectional aortic diameter at the level of the ARSA was 31.8 ± 8.5 mm for the entire cohort. For the patients who had initially been observed and had subsequently required intervention, the largest change in the ARSA cross-sectional diameter was observed 1 cm distally to the vessel ostium at a rate of 3.05 mm annually (95% confidence interval, 1.54-4.56; P < .001). No statistically significant changes in the annual growth rate of the aortic segments were observed in the entire cohort or for those patients who had undergone intervention (P > .05). ConclusionsThe decision to intervene on an ARSA should be individualized by the presence of symptoms (eg, dysphagia lusoria) or complications (eg, dissection, concomitant aortic aneurysmal disease, enlarging Kommerell diverticulum). Asymptomatic patients with nonaneurysmal ARSA might not require any intervention and can be safely observed. Measurement of the cross-sectional ARSA diameter 1 cm distally to the ostium of the vessel might aid in the surveillance of vessel diameter changes. Additional studies are required to determine the specific size criteria as an indication for operative repair of asymptomatic Kommerell diverticulum.

Hybrid repair of aberrant right subclavian artery with aortic dissection caused by Kommerell diverticulum

BackgroundAberrant right subclavian artery (ARSA) with associated Kommerell diverticulum (KD) is a rare congenital aortic disease. KD patients have a high risk of rupture, dissection, and compression of adjacent structures. Although several treatment options have been proposed (traditional surgery, hybrid operation, and endovascular intervention), a consensus regarding optimal surgical management has not yet been established.Case presentationA case of successful hybrid repair of distal aortic arch dissection aneurysm by dissecting KD and ARSA with debranching of right and left common carotid arteries, left subclavian artery, and stent grafting was presented.ConclusionsThe hybrid operation is suitable for elderly patients or those with high risks. Along with intervention, the hybrid operation needs to be developed as a minimally invasive method.

On-table fenestration of frozen elephant trunk graft to achieve aberrant subclavian artery perfusion.

On-table fenestration of frozen elephant trunk graft to achieve aberrant subclavian artery perfusion.

Aortic arch uncrossing using a tracheal resection procedure

One category of vascular rings is the right aortic arch associated with the diverticulum of Kommerell from which the left subclavian artery usually originates. In some cases, the right aortic arch crosses behind the trachea and the esophagus from right to left. The trachea and esophagus are compressed by the right aortic arch, the left ligamentum, and the posterior crossing aorta, which causes the typical symptoms of noisy breathing, dyspnea on exertion, dysphagia, and frequent upper respiratory tract infections. Division of the atretic arch segment between the diverticulum of Kommerell and the left common carotid artery may relieve the symptoms temporarily but does not relieve the compression produced by this vascular abnormality. Indeed, at the age of 10 months, this patient underwent anterior arch division and posterior aortopexy via a posterolateral thoracotomy in order to relieve the compression caused by the vascular ring. Several months after the initial operation, the patient had recurrent respiratory symptoms as a result of residual vascular compression from the circumflex arch. A CT scan and airway endoscopy confirmed tracheal compression; in addition, the tracheoscopy showed tracheomalacic changes in the compressed segment of the trachea. To relieve the symptoms and the compression, we decided to resect the tracheomalacic segment of the trachea and translocate the aortic arch anterior to the trachea and esophagus.

Trends in Endovascular Management of Aberrant Subclavian Artery With Kommerell Diverticulum

Most patients with aberrant subclavian artery (ASA) are asymptomatic, and this congenital anomaly is often found incidentally. Kommerell diverticulum (KD), which typically occurs at the proximal origin of ASA, may arise in up to 60% of patients with ASA. 1 Molz G. Burri B. Aberrant subclavian artery (arteria lusoria): sex differences in the prevalence of various forms of the malformation. Evaluation of 1378 observations. Virchows Arch A Pathol Anat Histol. 1978; 380: 303-315 Crossref PubMed Scopus (87) Google Scholar ,2 Simon R.W. Lachat M. Pfammatter T. Amann-Vesti B.R. Giant aneurysm of an aberrant right subclavian artery from the left aortic arch. J Thorac Cardiovasc Surg. 2006; 132: 1478-1479 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar KD increases the risk of acute aortic dissection or rupture as it grows in size. In this issue of The Annals of Thoracic Surgery, Fukuhara and colleagues 3 Fukuhara S. Ahmed Y. Shiomi S. et al. Aberrant subclavian arteries and associated Kommerell diverticulum: endovascular vs open repair. Ann Thorac Surg. 2022; 114: 2163-2172 Abstract Full Text Full Text PDF Google Scholar examine their 20-year single-institution experience and identified 43 patients with ASA who underwent surgical repair. Among these 43 patients, 26 were treated with an endovascular approach and 17 with open surgery. KD was found in more than 80% of patients. Aortic dissection accounted for 33% of patients. Although all patients were treated with an open approach until 2006, an endovascular approach has been performed frequently since then, and 74% of patients had an endovascular approach between 2014 and 2019. Fukuhara and colleagues 3 Fukuhara S. Ahmed Y. Shiomi S. et al. Aberrant subclavian arteries and associated Kommerell diverticulum: endovascular vs open repair. Ann Thorac Surg. 2022; 114: 2163-2172 Abstract Full Text Full Text PDF Google Scholar showed favorable outcomes with an endovascular approach compared with an open approach, including a shorter length of hospital stay, a lower incidence of pneumonia, and a shorter duration of mechanical ventilation, whereas other complications seemed equivalent, such as in-hospital mortality, stroke, paralysis, and peripheral vascular complications. Although the mean follow-up duration was 7.3 years in open approach group, the endovascular approach group was followed up for a mean of 4 years. Despite the short follow-up, 21% of patients required reintervention. Aberrant Subclavian Arteries and Associated Kommerell Diverticulum: Endovascular vs Open RepairThe Annals of Thoracic SurgeryVol. 114Issue 6PreviewVarious surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum. Full-Text PDF

Aberrant Subclavian Arteries and Associated Kommerell Diverticulum: Endovascular vs Open Repair

BackgroundVarious surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum. MethodsBetween 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed. ResultsNo mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection. ConclusionsThe treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.