Aberrant Right Subclavian Artery and Axillary Artery Cannulation in Type A Aortic Dissection Repair Bektas Battaloglu, MD, Serkan Secici, MD, Cengiz Colak, MD, Olcay M. Disli, MD, Nevzat Erdil, MD, and Ramazan Kutlu, MD Departments of Cardiovascular Surgery and Radiology, Inonu University Faculty of Medicine, Malatya, Turkey Currently, right axillary artery cannulation and unilateral antegrade cerebral perfusion through the same cannula are preferred choices for acute type A aortic dissection repair. However, the existence of an aberrant right subcla- vian artery can jeopardize cerebral perfusion through the right axillary artery cannula. In this study, we intended to explain the repair of acute type A aortic dissection using right axillary artery cannulation in a patient with aberrant right subclavian artery. (Ann Thorac Surg 2013;96:e1–2) © 2013 by The Society of Thoracic Surgeons C urrently, whole body and cerebral perfusion through a single right axillary artery cannula for repair of acute type A aortic dissection is a popular method [1]. The presence of an aberrant right subclavian artery (ARSA), which is an uncommon congenital variant of aortic arch, can lead to some difficulties, especially for unilateral cerebral perfusion through the same cannula [2]. In patients with ARSA, providing blood flow from right axillary cannula to the right common carotid artery is not possible; therefore, it crucial to be aware of ARSA. In this study, we present an example of a repair of acute type A aortic dissection in a patient with an aberrant right subcla- vian artery by using right axillary artery cannulation. A 53-year-old man was admitted to our hospital because of sudden onset of chest pain that spread toward his back. He had a history of mechanical aortic valve replace- ment (AVR) approximately 30 days earlier at another facility. A chest radiograph showed an enlarged upper mediastinal mass. Computed tomography revealed aortic dissection extending from just above the sinus of Val- salva to iliac arteries. Computed tomography also showed an aberrant right subclavian artery (Fig 1). The aberrant right subclavian artery originated from the distal aortic arch just below the left subclavian artery. Arch vessels arose from the true lumen. Preoperative echocardiography exposed no abnormalities related to the mechanical aortic valve. An emergent aortic repair was performed. The right axillary artery was cannulated as described previously [1], and a median resternotomy was performed. Next, a cardiopulmonary bypass was initiated after right atrial cannulation with a two-staged single venous cannula. Meanwhile, systemic cooling was started. The ascending aorta was cross-clamped in its midportion. An aortotomy was performed, and the proximal aorta was transected. The aortic wall was reinforced with two layers of felt strips, and proximal anastomosis was performed just at supracoronary level with 30-mm tube graft (Jotec Inc, Hechingen, Germany). Once proximal anastomosis was completed, the right and left common carotid artery were dissected from the surrounding tissues. The right carotid artery was cannulated selectively. When the rectal tem- perature reached 24°C, the right and left common carotid arteries were clamped with soft vascular clamps. Thus, unilateral antegrade cerebral perfusion was performed through the right carotid artery cannula. The aortic arch was transected from proximal of the left subclavian artery, and distal anastomosis was performed after rein- forcing the region. Next, the right and common carotid arteries were reimplanted onto the new aorta. The post- operative course was uneventful. His quality of life was good in his long term follow-up, and he was checked with computed tomography (Fig 2). Comment Aberrant right subclavian artery is an uncommon con- genital aortic arch anomaly, with a reported incidence of 0.2% to 1.7% [2]. It is often asymptomatic and is fre- quently discovered through incidental findings in imag- ing evaluations [3]. The aberrant right subclavian artery can also be involved in aortic dissection, although reports of aortic dissection with ARSA are few [4–6]. In this case, the patient had undergone aortic valve replacement, which is one of the most important predis- posing conditions for aortic dissection [7]. The anomaly was not discovered during his previous surgery. The coexistence of aortic dissection and undiscovered ARSA can be catastrophic if unilateral antegrade cerebral per- fusion through the right axillary artery is performed. It is important to consider such congenital arch anomalies when evaluating aortic dissection. At our institution, the usual strategy for acute type A Accepted for publication Jan 11, 2013. Address correspondence to Dr Battaloglu, Department of Cardiovascular Surgery, Inonu University Faculty of Medicine, Malatya, Turkey; e-mail: [email protected]. Fig 1. Computed tomography reveals aortic dissection and the aber- rant right subclavian artery. Arrow indicates the aberrant right sub- clavian artery. © 2013 by The Society of Thoracic Surgeons 0003-4975/$36.00 Published by Elsevier Inc http://dx.doi.org/10.1016/j.athoracsur.2013.01.044
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