Aberrant right subclavian artery: varied presentations and management options William M. Stone, MD, David C. Brewster, MD, Ashby C. Moncure, MD, David P. Franklin, MD, Richard P. Cambria, MD, and William M. Abbott, MD, Boston, Mass. Although an aberrant right subclavian artery arising from the proximal portion of the descending thoracic aorta is the most common aortic arch anomaly, few patients have clinical symptoms directly attributable to it. When symptoms do occur they are usually causally related to aneurysmal or occlusive sequelae of atherosclerotic disease of the anom- alous vessel. More unusual manifestations peculiar to the anomalous artery include an- eurysmal degeneration of the origin of the vessel from the aortic arch, with its inherent risk of rupture, or symptoms of compression of the trachea or more commonly the esophagus by the anomalous vessel as it traverses the superior mediastinum. In patients with symptoms a variety of operative approaches and management strategies have been used. Our recent experience with treatment of two patients with clinical symptoms caused by an aberrant right subclavian artery illustrate the varied surgical options and prompted a review of the surgical management of this unusual anomaly. (J VAsc SuRG 1990;11: 812-7.) Anomalous origin of the right subclavian artery from the aortic arch has been found in as many as 1 of 200 autopsies. 1 Although it represents the most common aortic arch anomaly, it causes symptoms only infrequently. Our recent experience with two patients with this anomaly prompted our review of the modes of presentation and the varied manage- ment options. CASE REPORTS Case 1. A 32-year-old woman had an evaluation for a recent onset of dysphagia, which had slowly increased in severity. She also complained of a flail sensation in her neck as though she had a "lump in her throat." On physical examination, she was found to be a healthy appearing 32-year-old woman with no contributing ab- normalities. Pulse examination was normal with equal up- per extremity blood pressures in both right and left arms. An upper gastrointestinal barium study was obtained and revealed a posterior filling defect in the esophageal lumen. The mucosa was smooth and without abnormality. En- dopscopy revealed a posterior extraluminal mass in the upper esophagus. This mass was noted to be pulsatile by From the Vascular Surgery Division, General Surgical Services, Massachusetts General Hospital, and Department of Surgery, Harvard Medical School, Presented at the Sixteenth Annual Meeting of the New England Society for Vascular Surgery, Bretton Woods, N.H., Sept. 21- 22, 1989. Reprint requests: William M. Stone, MD, Mayo Clinic Scottsdale, 13400 E. Shea Blvd., Scottsdale, AZ 85259. 24/6/20386 812 the endoscopist. On placement of pressure upon this mass with the tip of the endoscope, it was noted that the right radial pulse was obliterated. As a result of these findings a presumptive diagnosis of an aberrant right subclavian ar- tery was made, and the patient was transferred for evalu- ation. Arterial digital subtraction angiography (Fig. 1) was performed and revealed an aberrant origin of the right subclavian artery from the posterior aspect of the proximal descending thoracic aorta just distal to the origin of the left subclavian artery. The right common carotid artery originated directly from the aortic arch. The left common carotid and subclavian arteries were unremarkable. The aberrant subclavian artery was noted to pass behind ~ esophagus and had no aneurysmal or occlusive disease present. The patient was subsequently taken to the operating room and explored via a right supraclavicular incision. The aberrant right subclavian artery was identified and mobi- lized as proximally as possible with transection accom- plished to the left of the esophagus approximately 2 cm distal to its origin. The distal end of the aberrant vessel was then transposed to the right common carotid artery in an end-to-side fashion (Fig. 2). Electroencephalographic monitoring was used during carotid clamping. After the procedure the patient had an uncomplicated recovery with complete resolution of her dysphagia. Case 2. A 72-year-old man complained of progressive severe dysphagia of 1 year's duration and was in otherwise excellent health. He had no family history of aneurysmal disease but did give a 40 pack-year smoking history. On physical examination he was found to have some mild respiratory distress, which we thought related to tra-
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