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

Results

Operative Procedures

The operative procedures of the six patients treated are summarized in Table 1 . Five patients had elective surgery, whereas one patient was treated on an emergency basis for acute severe upper gastrointestinal hemorrhage. The first two patients were treated by open surgical procedures. After the introduction of endovascular stent graft techniques in our department, the following patients were preferentially treated by extrathoracic endovascular techniques. The occlusion of the origin of the lusorian artery at the proximal descending aorta was performed by a combined extrathoracic cervical-endovascular approach using homemade and third-generation commercial aortic stent grafts in combination with right subclavian artery transposition. Homemade stent grafts were constructed of a proximal and distal nitinol ring connected with a standard vascular tube prosthesis. In all patients treated by thoracic aortic stent graft implantation, right subclavian artery transposition was done, and transposition of both subclavian arteries was performed in one patient when additional overstenting of the left subclavian artery was intended.

Technical Success

Thoracic aortic stent graft implantation was technically feasible in all three patients treated for a symptomatic lusorian artery with no proximal or distal endoleak, complete aneurysm, or lusorian artery exclusion and patency for up to 92 months (see Table 1 ). In one patient, an additional Wall stent was implanted for a partial stent graft thrombosis. No type 1 endoleak was observed in the patients treated by a thoracic aortic stent graft.

Endoluminal transbrachial stenting of a lusorian artery aneurysm might be an additional treatment option if complete sealing of the aneurysm entry can be achieved, requiring suitable distal and proximal vascular configuration for stent graft fixation. However, as shown in our patient (case 6), persistent perfusion of the lusorian artery aneurysm was observed because of a proximal endoleak, with subsequent acute hemorrhage from an arterioesophageal fistula.

Neurologic Complications

No perioperative neurologic complications were observed in the group of patients treated electively for symptoms of an aberrant right subclavian artery. The only patient treated for an arterioesophageal fistula with acute hematemesis requiring a transaortic patch angioplasty with left heart extracorporal bypass and subsequent thoracic stent graft implantation had a territorial ischemia detected on cerebral CT scan and died perioperatively from acute cardiopulmonary failure.

Perioperative Mortality

The perioperative overall mortality rate of all patients operated on for a symptomatic lusorian artery was 1 in 6 (16.6%). No patients died following elective treatment (n ?=? 5).

Midterm Follow-Up

Follow-up results of the patients with symptomatic aberrant right subclavian arteries are shown in Table 1 . The mean survival of patients treated electively was 54.4 months (range 12–92 months). After exclusion from arterial perfusion, the diameter of lusorian artery aneurysms (patients 1–3) decreased between 20 and 40% during follow-up, corresponding to an absolute reduction in aneurysm diameter of 10 to 24 mm. Two patients with a symptomatic lusorian artery treated with transposition of the right subclavian artery and thoracic stent graft implantation as the primary treatment procedure showed promising symptom-free midterm survival times of 82 and 92 months.

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