Treatment Of Aberrant Subclavian Artery Research Articles

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum: Presented at the Society for Vascular Surgery Vascular Annual Meeting, Boston, Massachusetts, June 15-18, 2022.

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum: Presented at the Society for Vascular Surgery Vascular Annual Meeting, Boston, Massachusetts, June 15-18, 2022.

Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell's diverticulum

ObjectiveAberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset. MethodsPatients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak. ResultsOverall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms. ConclusionsTreatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate.

Surgical treatment of aberrant subclavian artery

To determine the indications and optimal surgical treatment of aberrant subclavian artery. There were 3 patients with aberrant subclavian artery with clinical manifestations such as dysphagia, shortness of breath, weight loss, cough and chest pain between 2005 and 2020. Right-and left-sided aberrant artery was observed in 2 and 1 case, respectively. Supraclavicular unilateral or bilateral access depended on the side of aberrant artery. Carotid-subclavian anastomosis was performed. All patients were discharged without any symptoms. Close location of aberrant subclavian artery to common carotid artery can disturb circulation in brain and upper limb. Abnormal discharge of subclavian artery can cause compression of nearby organs (esophagus, trachea). Abnormal vascular discharge does not always have clinical manifestations that do not require surgical correction. Only symptomatic patients are subjects to surgical correction of aberrant subclavian artery. Knowledge of variant anatomy of supra-aortic vessels can minimize the risk of complications.

Treatment of aberrant subclavian artery combined with aortic dissection and analysis of interim results

Objective This retrospective study is to investigate the clinical features,treatment methods,and follow-up results of aberrant subclavian artery (ASA) combined with aortic dissection (AD). Methods Totally 17 patients with ASA combined with AD (ASA+AD) admitted to our hospital from August 2013 to February 2018,were included. Among these patients,there were 14 acute cases and 3 chronic cases; 13 males and 4 females; aged from 28 to 82 years,with the mean age of (54±14) years. All the ASAs in these 17 patients were located behind the esophagus. There were 15 cases of aberrant right subclavian artery (ARSA),including 13 cases of Stanford type B AD (TBAD) and 2 cases of Stanford type A AD (TAAD). The other 2 cases of aberrant left subclavian artery (ALSA) was combined with TBAD. In these 15 patients combined with TBAD,8 cases received the hybridization treatment,4 patients underwent the simple transluminal stent-graft placement,and 3 cases were subjected to the conservative treatment. All the other 2 patients combined with TAAD received the surgical treatment. Results Out of these 17 patients,16 cases were successfully followed up,while 1 patient was lost in the follow-up period (who received the conservative treatment). The follow-up period lasted from 5 to 58 months,with an average of (30±15) months. In the patients receiving the hybridization treatment,1 case reported perioperative death,and another 1 case suffered from severe endoleakage. In the patients receiving the simple transluminal stent-graft placement,1 case reported coldness in right upper extremity,combined with numbness. One case receiving the surgical treatment reported severe endoleakage within 3 months after operation. Moreover,2 cases reporting severe inner leakage underwent the secondary embolization treatment,obtaining satisfactory embolization effects. For the one case reporting coldness in right upper extremity,combined with numbness,after endovascular repairing treatment,the symptoms were significantly relived after drug treatment,without surgical treatment. No sever complications had been reported for the other patients during the follow-up period. Conclusion Patients with ASA+AD should be clearly diagnosed before surgery,and specific surgical plans should be determined according to specific conditions. Surgical treatment should be preferred for the patients of ASA combined with TAAD. For the patients of ASA combined with TBAD,the TEVAR or hybridization treatment or fenestration treatment could be considered,according to the condition of the arch branch vessels. Key words: Subclavian artery; Aorta; Aneurysm, dissecting; Radiology, interventional; Vascular surgical procedures

Invited Commentary

Management of Kommerell’s diverticulum associated with aberrant subclavian artery reconstruction remains controversial, partly because it is such a rare anomaly. Airway compromise is uncommon and typically presents early in life. Difficulties with swallowing are frequent and are often underestimated by both patients and clinicians. Most patients present as adults, presumably because of ongoing diverticular growth. The diverticulum represents the remnant of the fourth primitive dorsal arch and is typically seen as a conical origin of the aberrant vessel. Even when its absolute size is only mildly increased, the vessel is rather thin and friable, possibly reflecting the failed tissue involution programming. Because of such intrinsic tissue abnormality, Backer and colleagues [1Backer C.L. Russell H.M. Wurlitzer K.C. et al.Primary resection of Kommerell diverticulum and left subclavian artery transfer.Ann Thorac Surg. 2012; 94: 1612-1618Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar] had proposed a ratio of 1.5 between the diameter at the mouth of the diverticulum and at the distal subclavian as the trigger to consider intervention. In this issue of The Annals of Thoracic Surgery, Ikeno and colleagues [2Ikeno Y. Koda Y. Yokawa K. et al.Graft replacement of Kommerell diverticulum and in situ aberrant subclavian artery reconstruction.Ann Thorac Surg. 2019; 107: 770-779Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar] report excellent results of surgical treatment of aberrant subclavian artery with Kommerell’s diverticulum in 17 patients over an 18-year period. Even within a group with an interest in arch anomalies such interventions were performed about once a year. It is remarkable that only 6 of 17 patients were symptomatic. Dysphagia progresses so slowly that many affected individuals are not even aware of their abnormal swallowing and are surprised by the strikingly different swallowing experience after the aberrant subclavian artery and diverticulum have been removed. However, in light of how well most patients are able to compensate for swallowing difficulties, it is imperative that our surgical treatment carry minimal mortality and morbidity. These authors have demonstrated outstanding results in the elective setting. Given the relatively focal aortic disease the option of endovascular treatment has been favorably considered by an increasing number of cardiovascular surgeons. In most instances the distance between the two subclavian arteries, which are typically 90 degrees off axis of each other, remains exceedingly short such that to achieve a seal at the proximal landing zone requires bilateral carotid-subclavian bypass/transposition. Even after adequate seal is achieved, the aberrant subclavian artery remains in situ and can continue to provide ongoing swallowing difficulty. Because most patients present early in their adult life an open intervention remains a low risk endeavor with predictably good long-term results. We have historically undertreated aberrant subclavian artery with Kommerell’s diverticulum for fear of causing more harm than good: Clearly only a high volume aortic center should tackle these rare anomalies to ensure negligible risk. The surgical treatment of aberrant subclavian artery should include removal of the aberrant vessel with suitable revascularization plus excision of Kommerell’s diverticulum with appropriate aortic reconstruction. Endovascular treatment should be considered in high-risk patients primarily to treat impending rupture. Graft Replacement of Kommerell Diverticulum and In Situ Aberrant Subclavian Artery ReconstructionThe Annals of Thoracic SurgeryVol. 107Issue 3PreviewThis study aimed to evaluate the early and long-term outcomes of graft replacement of Kommerell diverticulum and in situ reconstruction of aberrant subclavian arteries in adults. Full-Text PDF

Aberrant Subclavian Artery Pathologies and Kommerell's Diverticulum: A Review and Analysis of Published Endovascular/Hybrid Treatment Options

Aberrant subclavian artery (ASA) is one of the most common congenital vascular anomalies of the aortic arch. The incidences of aberrant right subclavian artery (ARSA) and aberrant left subclavian artery (ALSA) are 0.4% to 2.3% and 0.05%, respectively. Approximately 60% of ARSA patients will have a Kommerell's diverticulum at the origin of the ASA. Symptomatic or aneurysmal ASAs need to be treated. Historically, open operation was the favored method to reconstruct ASA anatomy; however, novel endovascular techniques are now available. Following a brief discussion of embryonic development, symptoms, and treatment history of the ASA and Kommerell's diverticulum, the results of a literature review to collect the worldwide experience of endovascular/hybrid treatment of ASA is presented.