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OBJECTIVES:
Aberrant right subclavian arteries are an uncommon congenital vascular anatomy with an incidence of 0.4-2.3% of the population. Aberrant right subclavian arteries result from failure of normal aortic arch regression. Normally, the dorsal aortic roots give rise to six pairs of aortic arches that then go through a series of regression to give rise to normal anatomy. Failure of this to occur in the right fourth arch and right dorsal aorta results in aberrant right subclavian anatomy. The aberrant subclavian artery will begin within the descending thoracic aorta typically passing posterior to the esophagus and anterior to the spine. This aberrant course can cause esophageal compression resulting in dysphagia. Aneurysmal degeneration can lead to further compression of surrounding structures and often times fatal rupture.
METHODS:
Two patients were found to have aneurysmal degeneration of an aberrant right subclavian artery. One patient underwent an extensive workup for ongoing dysphagia with serial endoscopies and esophageal dilations. A CT scan of the chest was eventually performed which revealed the aberrancy with associated aneurysmal changes. The second patient presented to an outside ED with chest and back pain. A CT scan revealed a large 10 cm aneurysmal aberrant right subclavian artery. This was repaired emergently with endograft and carotid subclavian bypass and proximal ligation as it was a contained rupture. The other patient underwent elective repair with a thoracic endograft with right carotid-subclavian bypass and staged left carotid-subclavian bypass.
RESULTS:
Both aneurysms were successfully managed through a combined open and endograft approach. Post operatively CT surveillance has demonstrated no aneurysm growth. The first patient did require resection of his right carotid to subclavian bypass secondary to a graft infection. He was involved in a motor vehicle accident with a prolonged hospital stay. He became septic with MRSA pneumonia that presumably seeded his bypass. A carotid to axillary bypass with autogenous vein was performed followed by total graft excision. Both patients continue to do well.
CONCLUSIONS:
Aberrant right subclavian arteries are an uncommon entity seen in the general population but the incidence can be projected to increase with the greater use of CT imaging. A high index of suspicion is needed. Repair of an aberrant right subclavian artery can be accomplished successfully using endograft exclusion with open revascularization.