Ann Thorac Surg 2004;77:2196-2197
© 2004 The Society of Thoracic Surgeons
Case report
Successful repair of aberrant right subclavian artery aneurysm combined with bicuspid aortic valve through a median sternotomy
Tetsuya Kono, MDa*,
Hiroto Kitahara, MDa,
Takayuki Watanabe, MDa,
Tamaki Takano, MDa,
Masayuki Sakaguchi, MDa,
Jun Amano, MDa
a Department of Cardiovascular Surgery, Shinshu University School of Medicine, Matsumoto, Japan
Accepted for publication June 6, 2003.
* Address reprint requests to Dr Kono, Department of Cardiovascular Surgery, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto 390-8621, Japan
e-mail: tetsuya{at}hsp.md.shinshu-u.ac.jp
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Abstract
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We report a case of a successfully repaired aberrant right subclavian artery aneurysm combined with bicuspid aortic valve using a multibranched vascular prosthesis. Approaching solely through a median sternotomy under cardiopulmonary bypass, hypothermic circulatory arrest, and selective cerebral perfusion, we performed a successful single-stage correction by aortic valve replacement, resection of aneurysm, and reconstruction of the right subclavian artery.
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Introduction
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Aberrant right subclavian artery (RSA) aneurysms are relatively rare lesions and surgical repair of the aneurysm is performed by a number of approaches [1, 2].
To ensure exposure of the origin of the aberrant artery and access for revascularization, left thoracotomy with revascularization via carotid-subclavian bypass through a second incision is often used [2]. In this article we report the successful repair of an aberrant RSA aneurysm, combined with bicuspid aortic valve, using a Gelweave multibranched vascular prosthesis (Vasctek Ltd, Renfrewshire, UK) solely via median sternotomy.
The patient was a 68-year-old male, with a history of hypertension, heavy cigarette smoking, and diabetes mellitus, who demonstrated a mediastinal mass on routine chest roentgenogram. In summer 2001, he developed dyspnea and subsequently experienced chest pain. Ultrasound cardiography showed calcified bicuspid aortic valve with a pressure gradient 70 mm Hg. Computed tomography (CT) of the chest demonstrated a mediastinal mass posterior to both the trachea and esophagus. The mass is associated with aberrant RSA and is consistent with an aneurysm of the vessel. Three-dimensional reconstructions further defined the 4.5 cm aneurysm and the origin of the aberrant RSA from the posteromedial aspect of a normally postioned, left-side descending aorta (Fig 1). Since the risk of spontaneous rupture of an aneurysm of this size is considered high, elective surgical resection and revascularizaton was planned. We thought single-stage correction of aortic valve replacement, resection of aneurysm, and reconstruction of RSA was the optimal choice; we selected median sternotomy approach under cardiopulmonary bypass (CPB), hypothermic circulatory arrest, and selective cerebral perfusion. First, CPB was established by cannulation of the ascending aorta and the right atrium, and aortic valve replacement using Carpentier-Edwards Bioprosthesis 21A (Edwards Ltd, California, USA) was performed. The aortic valve was congenitally bicuspid and severely calcified. Then hypothermic circulatory arrest and selective cerebral perfusion with core temperature of 20 degrees centigrade were established, aneurysmectomy, total arch replacement, and reconstruction of the RSA were performed using a Gelweave multibranched vascular prosthesis 24 mm. Cardiopulmonary bypass time, selective cerebral perfusion time, and hypothermic circulatory arrest time were 320 minutes, 211 minutes, and 70 minutes, respectively. Postoperatively, the patient experienced transient hoarseness but there was no neurologic disorder. Postoperative three-dimensional reconstructed CT showed no residual aneurysm (Fig 2).
The patient was discharged from the hospital on the 40th postoperative day and has continued to do well.
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Fig 1. Three-dimensional reconstructed computed tomography disclosed the 4.5-cm aneurysm and the origin of the aberrant right subclavian artery (RSA) from the posteromedial aspect aorta.
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Comment
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Aberrant RSA as the last brachiocephalic branch of the posteromedial aspect of the proximal descending aorta is the most common congenital anomaly of the aortic arch with an incidence of 0.5% to 1.0% [3]. It is 4 to 20 times more common than the right-sided arch with an aberrant left subclavian artery. In more than 80% of the cases, the vessel passes posterior to both the esophagus and the trachea.
Aberrant subclavian arteries are usually asymptomatic and are often discovered on radiologic studies for other pathology in a young age. In adulthood, approximately 5% of patients with aberrant RSA have been reported to become symptomatic due to the development of atherosclerotic rigidity, tortuosity, or occasionally, aneurysmal dilatation of the aberrant vessel [4]. An aneurysm at the origin of an aberrant RSA is relatively rare.
Since rupture is associated with 100% mortality and elective surgical repair carries an acceptable low morbidity and mortality rate, the aneurysm should be resected [1]. Several approaches to revascularizing the right arm have been described, including left thoracotomy with or without a cervical approach, an extrathoracic approach, or a median sternotomy [5]. Potential disadvantages of these techniques include difficulty in exposing of the posteromedial side of the aortic arch and the right lateral side of the ascending aorta; hence, less optimal control of hemorrhage, as well as the need to reposition the patient twice for two incisions.
In our experience an approach through a median sternotomy under CPB, hypothermic circulatory arrest and selective cerebral perfusion allows excellent exposure and complete resection of the aneurysm. This approach enabled relief of symptoms because it left a relatively long stump of aberrant RSA. In addition, such technique prevents the need for difficult and hazardous clamping of the aorta around the base of the often calcified aneurysm. As for reconstruction of RSA, it was easily performed by anastomosing the graft branch of a multibranched vascular prosthesis to the RSA; since resection of the aortic arch provides excellent exposure of the right lateral ascending aorta.
In conclusion, we describe the successful surgical repair of an aberrant RSA aneurysm combined with bicuspid aortic valve using a Gelweave multibranched vascular prosthesis. Solely through median sternotomy approach under CPB, hypothermic circulatory arrest and selective cerebral perfusion, we performed a single-stage procedure achieving aortic valve replacement, resection of aneurysm, and reconstruction of RSA without difficulty.
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References
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- van Son J.A.M., Mierzwa M., Mohr F.W. Resection of atherosclerotic aneurysm at origin of aberrant right subclavian artery. Eur J Cardiothorac Surg 1999;16:576-579.[Abstract/Free Full Text]
- Myers J.L., Gomes M.N. Management of aberrant subclavian artery aneurysm. J Cardiovasc Surg 2000;41:607-612.[Medline]
- Stewart J.R., Kincaid O.W., Edwards J.E. An atlas of vascular rings and related malformations of the aortic arch system. . Springfield, MA: Charles C Thomas, 1964.
- Beabout J.W., Steward J.R., Kincaid O.W. Aberrant right subclavian artery: dispute of commonly accepted concepts. Am J Roentgenol 1964;92:855-864.
- van Son J.A.M., Julsrud P.R., Hagler D.J., et al. Surgical treatment of vascular rings: The Mayo Clinic experience. Mayo Clin Proc 1993;68:1056-1063.[Medline]
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Abstract
Introduction
