Surgical and Endovascular Treatment of Symptomatic Aberrant Right Subclavian Artery (Arteria Lusoria)

Reinhard Kopp; Ingrid Wizgall; Eckart Kreuzer; Georgios Meimarakis; Rolf Weidenhagen; Andreas Kühnl; Claudius Conrad; Karl Walter Jauch; Lutz Lauterjung

Disclosures

Vascular. 2007;15(2):84-91. 

In This Article

Patients and Methods

We report six patients treated for a symptomatic aberrant right subclavian artery in our department between 1988 and 2005. Every patient is presented in detail in the following text, and a summary of all patients is provided in Table 1 .

Case 1

A 75-year-old female patient was admitted to the hospital because of persistent left-sided thoracic pain with projection to the left arm.[18] After exclusion of acute myocardial infarction or pulmonary embolization, a chest radiograph showed a right mediastinal mass and selective angiography of the aortic arch revealed an arteria lusoria aneurysm (diameter 5 cm). Three years previously, the patient was treated for an infrarenal abdominal aneurysm by tube graft aortic replacement. The lusorian artery aneurysm was excluded by left-sided thoracotomy and clamping and ligation of the lusorian artery proximal and distal from the aneurysm. Transposition of the right subclavian artery was not performed because of intraoperative evidence of sufficient retrograde blood flow. Postoperative systolic blood pressure in the right arm was 60 mm Hg compared with 130 mm Hg in the left arm. The remaining postoperative course was uneventful, and the patient was well after a 12-month follow-up.

Case 2

An 80-year-old male patient had clinical symptoms of dysphagia in association with an aberrant right subclavian artery and an aneursym that was 4.5 cm in diameter (fig 1). Contrast examination of the esophagus showed high-grade stenosis of the proximal esophagus (fig 2). The patient had undergone upper partial gastrectomy for early proximal gastric cancer 1 year earlier. In addition, the patient has had acute replacement of the infrarenal aorta by a bifurcated prosthesis because of an symptomatic aortoiliac aneurysm and was treated for severe coronary heart disease, diabetes mellitus, compensated renal insufficiency, and arterial hypertension.

Figure 1.

Computed tomographic angiogram of the aberrant right subclavian artery and the lusorian artery aneurysm as presented in case 2.

Figure 2.

Esophagogram showing compression of the esophagus because of an aberrant right subclavian artery aneurysm.

Lusorian artery aneurysm was excluded by ligation of the proximal origin at the level of the proximal descending thoracic aorta and distally from the aneurysm by left-sided thoracotomy. The patient underwent surgery again on the same day because of postoperative bleeding at the site of the aortic suture. The patient was discharged on the thirteenth postoperative day, and the postoperative course was then uneventful. During reexamination of the patient 2 years later, the arteria lusoria aneursym had decreased and the proximal esophageal stenosis had disappeared. The patient died suddenly 28 months later at the age of 82 years.

Case 3

A 73-year-old female patient had recurrent bronchitis and persistent dyspnea. She also had arterial hypertension and coronary heart disease treated with an aortocoronary bypass in the same year. Computed tomographic (CT) scan revealed an arteria lusoria aneurysm (diameter 6.5 cm) with dorsal compression of the treachea.

A lusorian artery aneurysm was excluded by implantation of a thoracic aortic homemade stent graft, followed by transposition of the right subclavian artery to the right common carotid artery. Prior to stent graft implantion into the proximal thoracic aorta, with intentional occlusion of the origin of the left subclavian artery, transposition of the left subclavian artery to the left common carotid artery was performed. Postoperative angiography and CT showed complete exclusion of the lusorian artery aneurysm (fig 3). One year later, an infrarenal abdominal aortic aneurysm was excluded by open surgical implantation of a tube prosthesis. Repeated CT scans showed the correct positioning of the implanted thoracic stent graft and a reduced diameter of the lusorian aneurysm of 3.5 cm, without evidence of endoleak or migration. The patient died 82 months after the initial aneurysm exclusion of the lusorian artery because of acute myocardial infarction.

Figure 3.

Postoperative control angiogram (A) and computed tomographic scan (B) after implantation of the thoracic aortic stent graft to occlude the proximal aortic origin of the lusorian artery in case 3. Blood flow to the right and left arms was reconstructed by transposition of the subclavian artery to the common carotid artery on each side.

Case 4

A 33-year-old female patient complained of dysphagia and dyspnea. CT and selective angiography showed an aberrant right subclavian artery arising from a Kommerell's diverticulum from the dorsal proximal descending thoracic aorta. Operative treatment consisted of a combined surgical and endovascular approach by initial transposition of the right subclavian artery to the common right carotid artery and transfemoral homemade stent graft implantation into the proximal descending thoracic aorta to occlude the origin of the lusorian artery. Postoperative angiography revealed a partial thrombosis and kinking in the midportion of the aortic stent graft with neurologic signs of a pseudocoarctation syndrome, which was treated by an additional implantation of a self-expandable Wall stent (24 mm in diameter and 70 mm in length) into the graft. The postoperative course was without complications, the neurologic symptoms had disappeared, and the patient left the hospital on the eleventh postoperative day. During follow-up for 92 months, CT reexamination showed that the lusorian artery was still excluded and the thoracic aortic stent graft was in the correct position.

Case 5

A 72-year-old female patient was admitted because of persistent dysphagia. CT, angiography (fig 4), and contrast swallow examination confirmed the diagnosis of an aberrant right subclavian artery with moderate compression of the esophagus. The patient was treated by occlusion of the proximal lusorian artery via a transbrachial approach using a covered Wall stent with an occluded proximal stent graft lumen. The right subclavian artery was then transposed to the right common carotid artery. The postoperative course was uneventful, with immediate improvement in the initially reported dysphagia. The patient was still asymptomatic and alive 79 months after the endovascular exclusion of the lusorian artery.

Figure 4.

Angiography of an aberrant right subclavian artery causing dysphagia, as reported in case 5.

Case 6

A 77-year-old female patient was admitted because of acute hematemesis and hemorrhage. Initial endoscopic examination indicated possible bleeding from the dorsal esophageal wall in the proximal esophagus (approximately 15 cm distal from the dental line). Three months before, the patient was treated for unspecific vertigo in a different hospital, and further diagnostic procedures revealed an arteria lusoria aneurysm with a diameter of 7 cm. The aneurysm was endoluminally treated with two flexible and self-expandable stent grafts via a transbrachial approach. A control CT scan at discharge proved suspicious for remaining distinct perfusion of the lusorian artery aneurysm.

CT angiography at the time of admission to our hospital (fig 5) showed persistent perfusion of the aneurysm, and because of acute hematemesis, aneurysm perforation with an arterioesophageal fistula was suspected. The proximal end of the stent graft was localized within the lumen of the proximal descending thoracic aorta. To remove the stent graft and occlude the origin of the lusorian artery at the level of the proximal descending thoracic aorta, an open intraluminal aortic patchplasty was performed under extracorporal circulation via a left-sided thoracotomy. Distal transaxillar stent occlusion of the lusorian artery was performed to avoid retrograde perfusion. However, a postoperative CT scan (fig 5) still showed persistent antegrade flow within the lusorian artery and the aneurysm, caused by a leakage of the intraluminal aortic patch. To occlude this leak at the level of the former origin of the lusorian artery, a thoracic aortic stent graft (Cook Zenith, William Cook Europe, Bjaeverskov, Denmark; 26 mm in diameter) was implanted with complete sealing of the descending thoracic aorta. Although the risk of acute hemorrhage was now under control, the patient postoperatively developed increasing respiratory insufficiency and acute right heart failure in association with a right-sided tension pneumothorax and sudden cardiac arrest. Although the tension pneumothorax was immediately treated and cardiopulmonary resuscitation was initially successful, the patient died from progressive heart and respiratory failure 24 hours later.

Figure 5.

A, Computed tomographic (CT) angiogram showing a lusorian artery aneurysm (case 6) initially treated with transbrachial endoluminal stenting and persistent endoleak with lusorian artery aneurysm perfusion. Inset: An identical CT scan and presentation of the covered intraluminal stent graft within the lusorian artery showing the proximal end within the lumen of the proximal descending aorta. B, CT angiogram following transaortic patch angioplasty of the origin of the lusorian artery (case 6) with left heart extracorporal bypass, remaining perfusion of the lusorian aneurysm, and distal stent graft occlusion (white arrow) of the prevertebral right aberrant subclavian artery and prior to thoracic aortic stent graft implantation. Inset: Schematic presentation of the combined cervical-endovascular treatment of a ruptured type 3 lusorian artery, as described for this patient. Usually, we perform a transfemoral stent graft implantation into the proximal descending thoracic aorta with simple transposition and distal ligation of the lusorian artery instead of the shown distal transaxillar stent occlusion and the carotidosubclavian bypass. Transluminal aortic patchplasty (black arrow) was done exceptionally in this case, as mentioned in the Patients and Methods section.

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