Surgical Treatment of Recurrence of an Aneurysm of Aberrant Right Subclavian Artery

A bstract A 52-year-old woman underwent incomplete resection of an aneurysm of the aberrant right subclavian artery. Three years later she was hospitalized because of a right superior mediastinal mass on the chest X-ray and a new angiography revealed dilatation of the remaining part of the aberrrant right subclavian artery near its origin and involving the adjacent thoracic aorta and the distal aortic arch. At surgery, a left posterolateral thoracotomy in the fourth intercostal space was performed. Using deep hypothermia and circulatory arrest the aneurysm was excised and the aortic tract adjacent to the aneurysm was replaced with a Dacron prosthesis.     

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.     

Novel approaches for the treatment of the aberrant right subclavian artery and its aneurysms

We report a minimally invasive, hybrid endovascular approach that was used to treat two patients with aberrant right subclavian arteries. The first patient was a 50-year-old woman who presented with dysphagia lusoria. She underwent endovascular plugging and depressurization of the aberrant artery and a carotid-subclavian bypass using right supraclavicular access. The second patient, a 77-year-old woman who presented with a 5.5-cm aneurysm at the origin of a previously bypassed aberrant artery on the distal aortic arch, was treated using bilateral carotid-subclavian bypasses through neck incisions and a thoracic endoluminal graft exclusion of the arch aneurysm that covered both subclavian arteries.     

Anomalous vertebral artery origins: the first and second reports of two variants

We present two cases of aberrant origins of vertebral arteries. Case 1 is of a patient undergoing evaluation of an infrarenal aortic aneurysm stent graft. Computed tomography (CT) angiogram revealed an aberrant right vertebral artery that subsequently joined a second right vertebral artery that had the typical origin off the right subclavian artery. This represents an unusual anatomic variation not previously reported in the literature. Case 2 is of a patient being evaluated for thoracic aorta injury. CT angiogram of the chest revealed a five-vessel aortic arch with aberrant origin of the bilateral vertebral arteries distal to the left subclavian artery.     

Surgical treatment for thoracic aortic aneurysm with aberrant right subclavian artery

We present two operative cases of thoracic aortic aneurysm combined with aberrant right subclavian artery (ARSA). Case 1 was a 71-year-old man with a fusiform-type arch aneurysm. He underwent total aortic arch replacement to reconstruct all 4 arch branches. Case 2 was a 39-year-old man suffering from chronic DeBakey type IIIb dissection. He underwent total descending thoracic aortic replacement for the remaining ARSA. In both cases ARSA was diagnosed preoperatively by reconstructed three-dimensional computed tomography (3D-CT). Both patients followed uneventful postoperative courses with excellent results. 3D-CT is helpful for precise planning of surgical strategy in such cases.     

Thoracic aneurysm in association with an aberrant right subclavian artery

A case of a 45-year-old man is presented with clinical signs of a dissecting aortic aneurysm. Angiography and CT demonstrated a dissecting thoracic aneurysm (deBakey type III a) and an aberrant right subclavian artery arising from this aneurysm at the fourth branch of the aortic arch. In the first step, the aberrant artery was implanted into the right common carotid artery. In a second operation, the aneurysm was replaced by a Dacron tube. The advantage of our procedure is the perfusion of at least one vertebral artery during aortic cross-clamping and easier access to the aneurysm through a left thoracotomy. As far as we know, this is the fourth presentation of such a case in the literature in which the other cases concern angiographic or post-mortem findings.     

Gleichzeitige Durchführung von Debranching und endovaskulärer Versorgung eines rupturierten Aortenaneurysmas bei aberrierender A. subclavia rechts

A 62-year-old female patient with a known aberrant right subclavian artery (ARSA) and previous endovascular repair of Stanford type-B aortic dissection presented for follow-up. CT revealed a contained rupture of the proximal descending aorta with a maximum diameter of 80 mm involving the aortic arch and the origin of the ARSA. Combined debranching of the supra-aortic vessels via median sternotomy and endovascular obliteration of the thoracic aortic aneurysm was performed. The aberrant ARSA was ligated. Postoperative imaging showed excellent results without endoleak. The postoperative course confirmed tolerance of ARSA ligation. A hybrid approach to the proximal descending aorta is favorable even in cases of aberrant right subclavian artery. A team approach and appropriate planning is essential for success. The English full-text version is available at SpringerLink (under“Suppplemental”).     

Surgical treatment for thoracic aortic aneurysm with aberrant right subclavian artery

We present two operative cases of thoracic aortic aneurysm combined with aberrant right subclavian artery (ARSA). Case 1 was a 71-year-old man with a fusiform-type arch aneurysm. He underwent total aortic arch replacement to reconstruct all 4 arch branches. Case 2 was a 39-year-old man suffering from chronic DeBakey type IIIb dissection. He underwent total descending thoracic aortic replacement for the remaining ARSA. In both cases ARSA was diagnosed preoperatively by reconstructed three-dimensional computed tomography (3D-CT). Both patients followed uneventful postoperative courses with excellent results. 3D-CT is helpful for precise planning of surgical strategy in such cases.     

RIGHT AORTIC ARCH WITH ABERRANT LEFT SUBCLAVIAN ARTERY: ANEURYSMAL DILATATION CAUSING SYMPTOMATIC COMPRESSION OF THE RIGHT MAIN BRONCHUS IN AN ADULT

A 60 year old woman presented with a cough, nocturnal stridor and dysphagia. Bronchoscopy showed tight compression of the right main bronchus. Digital subtraction angiography (DSA) and a computed tomographic (CT) scan showed the presence of a right-sided aortic arch with aberrant left subclavian artery. The distal right arch and proximal right-sided descending thoracic aorta were aneurysmal and were responsible for this compression. Surgical relief was accomplished by dividing the aberrant left subclavian artery and replacing the aneurysm with a vascular graft.     

Coronary artery bypass grafting in a patient with right aortic arch; report of a case

A 60-year-old man was admitted to another hospital because of chest oppression on effort. Chest X-ray showed radiographic evidence of a right aortic arch and double vessel coronary artery disease with 50% stenosis in the left main trunk was diagnosed by coronary angiography. He was transferred to our institute for surgical treatment of angina pectoris. Preoperatively, multi-detector row computed tomography (CT) was performed and it revealed a right aortic arch and an aberrant left subclavian artery with narrow left internal thoracic artery. A right internal thoracic artery was well demonstrated. Therefore, conventional coronary artery bypass grafting using a right internal thoracic artery and a saphenous vein graft was performed and his postoperative course was uneventful.     

Total arch replacement for a distal arch aneurysm with aberrant right subclavian artery

Aberrant right subclavian artery is a rare condition with a prevalence of 0.5%-2.0% of the population. We report a case of distal aortic arch aneurysm with right subclavian artery. A 75-year-old man who was asymptomatic was referred to our hospital for a thoracic aortic aneurysm. Computed tomography showed a 55-mm fusiform aneurysm of the distal arch and an aberrant right subclavian artery. Total arch replacement was performed via median sternotomy with antegrade selective cerebral perfusion and hypothermic circulatory arrest. We reconstructed the aberrant right subclavian artery in the normal position to avoid compression of the esophagus and trachea caused by future aneurysmal dilatation of the orifice of the aberrant right subclavian artery and potential high risk for rupture.     

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.     

Carotid artery stenting in a patient with right-sided aortic arch with an aberrant left subclavian artery

A right-sided aortic arch with an aberrant left subclavian artery is a rare anatomical variation. We report a case treated with carotid artery stenting (CAS) for a patient with a right-sided aortic arch with an aberrant left subclavian artery. A 72-year-old man presented right hemiparesis due to acute brain infarction. Neck CT angiography showed 70% stenosis in the left internal carotid artery (ICA). We diagnosed acute brain infarction as artery-to-artery embolism due to ICA stenosis and decided to perform carotid artery stenting (CAS) for symptomatic ICA stenosis. CT angiography to evaluate an access route to the lesion incidentally showed the right-sided aortic arch with an aberrant left subclavian artery. An intraoperative aortogram showed a right-sided aortic arch. The guiding catheter was carefully introduced up to the left common carotid artery. CAS was performed with a proximal balloon and distal filter protection. The stenotic area was restored, and the patient was discharged without suffering recurrent attacks. Although a right-sided aortic arch with an aberrant left subclavian artery is a very rare anatomical variation, it can be encountered in neuroendovascular treatment, and therefore knowledge of this anatomical variation is important.     

Left pulmonary artery occlusion due to compression by aortic aneurysm

A 72-year-old man with shock was transferred to our emergency room. The computed tomograms revealed a ruptured giant thoracic aortic aneurysm obstructing the left pulmonary artery. Emergency total aortic arch replacement was performed, and the postoperative course was uneventful. The postoperative angiography confirmed the total occlusion in the left pulmonary artery which was due to compression by the aortic aneurysm.     

Two cases of stent graft repair for thoracic aortic dissection: usefulness of three-dimensional computed tomogram]

We carried out stent graft repair in two patients with Stanford type B thoracic aortic dissection. A 51-year-old male was admitted to our hospital because of thoracic aortic dissection. Chest CT revealed an aneurysm of the distal aortic arch. The entry was pointed out 1 cm distal from the take off of the left subclavian artery in three-dimensional CT (3 D-CT). He was treated with a Gianturco stent which was anchored into the 30 mm Hemashield graft under selective cerebral perfusion. Another case was a 72-year-old male with a descending aortic aneurysm. 3 D-CT showed that the entry existed 4 cm proximal to the celiac artery. We performed transluminal implantation of the spiral Z-stent covered with the woven Dacron graft. 3 D-CT was useful for the preoperative management and the surgical treatment of thoracic aortic dissection.     

Surgical therapy of ruptured aortic aneurysm involving a Shuford type-3 right-sided aortic arch

A 64-year-old man was admitted to our hospital with a complaint of severe back pain of sudden onset on Nov. 2, 1988. Aortogram and chest-CT demonstrated a ruptured dissecting aortic aneurysm involving a Shuford type-3 right-sided aortic arch. Emergency operation was done under temporary brachio-femoral arterial bypass. The thoracic aorta was transected distal to an aberrant left subclavian artery. The entry which located proximal to the aberrant subclavian artery was closed by two u-stay sutures with pledgets. The transected aorta was closed and reinforced with Sandwich method using Teflon-felt. The false lumen completely disappeared on chest-CT on 36th day postoperatively, and the patient is now doing well, although re-thoracotomy was necessary because of post-operative bleeding. To our knowledge, this is the first case of repair of a ruptured dissecting aortic aneurysm involving a right-sided aortic arch which is reported to be very rare.     

Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

A successful surgical case of DeBakey IIIb dissecting aortic aneurysm in association with right aortic arch

A case of chronic DeBakey IIIb dissecting aneurysm in association with right aortic arch is reported. A 49-year-old man having encountered an aortic dissecting episode two years ago, was examined more closely because the aneurysm became larger recently. Digital subtraction angiography (intra-venous and intra-aortic) showed DeBakey IIIb dissecting aneurysm associated with a right aortic arch with aberrant subclavian artery. The entry of the aneurysm was in the right descending aorta passing from left thorax to right. The operative indication was for enlarged false lumen in this case. Graft replacement of the aneurysm and closure of the false lumen in the right thorax was performed under partial cardiopulmonary bypass through right thoracotomy. Postoperative digital subtraction angiography showed that dissection was in the abdominal aorta but false lumen in the thorax was completely closed. The patient has made a comeback working. A case of dissecting aortic aneurysm associated with right aortic arch is extremely rare. To our knowledge, this is the third such case reported in Japan, but the first case of a successful graft replacement for dissecting aortic aneurysm associated with right aortic arch.