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OBJECTIVES: Aberrant right subclavian artery (ARSA) is a rare anatomical finding resulting from abnormal embryologic development of the dorsal aorta and subsequently the right subclavian artery. Frequently, an aortic out pouching, or Kommerell diverticulum (KD) is present at the ARSA aortic origin. Patients may present with “dysphagia lusoria” if the ARSA and KD compresses the esophagus posteriorly. Given the historically high rate of rupture, early repair is indicated. Since the first repair (1971), treatment involved a thoracotomy with aneurysm exclusion. Presently, successful exclusion can be accomplished with thoracic endovascular stent grafting combined with carotid-subclavian bypass to maintain flow to the upper extremities. We present a successful repair of a symptomatic (dysphagia, weight loss) ARSA with KD using this hybrid open-endovascular approach.
METHODS: Pre-operative imaging included CT angiography of the chest (Figure 1), revealing a 3.5cm KD. Staged, bilateral carotid-subclavian bypass with ligation of the proximal subclavian arteries were performed using heparin-bonded polytetrafluroethylene graft (PTFE, Gore^® Propaten, W. L. Gore & Associates, Inc. Flagstaff, AZ ^®). A thoracic endovascular stent graft (Gore^® TAG^®) was then placed via percutaneous femoral access to exclude the KD. A review of the current literature for this rare problem was performed.
RESULTS: Completion arteriography and subsequent CT angiography demonstrated exclusion of the ARSA and KD without evidence of endoleak. Follow-up at one month revealed resolution of dysphagia, weight gain and symmetric radial pulses. A PUBMED literature review of 33 cases performed from 1998-2012 reveals good early and mid-term results using endovascular and hybrid procedures.
CONCLUSIONS: Staged subclavian revascularization followed by thoracic endovascular stent grafting with distal ARSA ligation offers decreased mortality and morbidity compared to open repair for ARSA with KD. Thoracic endovascular stent grafting to exclude the ARSA/KD, with distal ligation and reconstruction is evolving as validated technique for patients with ARSA and KD given better patient outcomes and a decreased mortality.