Aberrant subclavian artery division and revascularization by a supraclavicular approach for definitive or staged treatment of dysphagia lusoria Bryan V. Dieffenbach, MD, Gaurav Sharma, MD, Samir K. Shah, MD, Matthew T. Menard, MD, and Michael Belkin, MD, Boston, Mass ABSTRACT Objective: There is no consensus on the optimal approach to treatment of dysphagia lusoria (DL), especially in the absence of a Kommerell diverticulum (KD). We leveraged our institutional experience to clarify the safety and efficacy of aberrant subclavian artery (aSA) division with revascularization by a supraclavicular approach alone in patients with DL. Methods: We identified 10 consecutive patients who underwent surgery for DL at our institution between January 2007 and March 2019. Clinical and radiographic characteristics for all patients were collected. The primary outcome was improvement in dysphagia symptoms. Secondary outcomes included need for second-stage operation, postoperative complications, and long-term radiologic changes in the aSA remnant. Results: Seven patients underwent initial division of the aSA followed by revascularization through a supraclavicular exposure, and three had simultaneous supraclavicular and transthoracic intervention. Median follow-up was 52 (range, 1-143) months. In the four patients without a KD, a supraclavicular approach alone resulted in improvement in dysphagia symptoms. Conversely, the three patients who had a KD did not have durable relief of dysphagia and required a second- stage transthoracic procedure. Postoperatively, one developed a pulmonary embolism after supraclavicular approach alone and two patients developed complications after transthoracic intervention: left recurrent laryngeal nerve neu- rapraxia and pleural effusion requiring thoracentesis in one, and thoracic duct injury requiring reoperation in the second. Among those who underwent a single-stage procedure by a supraclavicular approach alone, no patients had aneurysm progression, rupture, or dissection after median follow-up of 60 (range, 1-100) months. Conclusions: Division and revascularization of the aSA through a supraclavicular exposure in patients with DL result in durable symptomatic improvement in the majority of patients, particularly those without a concomitant KD. Patients with a KD may require a second-stage procedure to address the KD, but it appears safe to trial staged intervention rather than simultaneous operations to divide the aSA and to address the KD. (J Vasc Surg 2020;72:219-25.) Keywords: Dysphagia lusoria; Aberrant subclavian artery; Kommerell diverticulum Aberrant subclavian artery (aSA) is the most common congenital anomaly of the aortic arch and occurs in about 0.7% of the general population. 1 The aSA arises from the posteromedial aspect of the descending aortic arch and traverses the midline before assuming the normal anatomic course contralaterally. 2 Most patients with this anomaly are asymptomatic. A minority of cases present with aSA dilation, known as a Kommerell diver- ticulum (KD) when degeneration occurs at the aSA origin, and dysphagia due to extrinsic compression of the esophagus, referred to as dysphagia lusoria (DL). 3 DL was first described by Bayford in 1794, 4 and although rare, it is reported as the most common indication for surgical intervention for aSA. 5 Robert E. Gross 6 was the first to describe operative intervention for DL, consisting of left anterolateral thora- cotomy and division of the aSA at the aortic takeoff without revascularization of the subclavian artery. Since then, a variety of surgical techniques to address these sequelae of aSA have been described. Approaches range from traditional open techniques to hybrid-endovascular treatments. 5,7-13 To date, there is no consensus on the optimal approach to treatment of DL, especially in the absence of KD. We leveraged our institutional experience to clarify the efficacy and safety of aSA division and revascularization by the supraclavicular approach alone in patients with DL. METHODS Study design and participants. This is a retrospective cohort study of 10 consecutive adult patients who under- went surgical therapy for DL at our institution between January 1, 2007, and March 1, 2019. Institutional Review Board approval was obtained before data collection. From the Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital. Author conflict of interest: none. Correspondence: Bryan V. Dieffenbach, MD, Division of Vascular and Endovas- cular Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214 Copyright Ó 2019 by the Society for Vascular Surgery. Published by Elsevier Inc. https://doi.org/10.1016/j.jvs.2019.09.037 219
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