Hybrid repair of a proximal right subclavian artery pseudoaneurysm in a patient with bovine aortic arch
Justin Milligan, MD, Abigail E. Barger, Animesh Rathore, MD, Limael E. Rodriguez, MD, Jurabek Babadjanov, MD, David Dexter, MD, Jean M. Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
DEMOGRAPHICS: 42-year-old Caucasian woman with no pertinent past medical or surgical history besides obesity and previous tobacco use (15 pack-years). Family history included coronary artery disease, hypertension and diabetes.HISTORY: She underwent cardiac catheterization (at outside institution) via right radial access for nonspecific chest pain and diffuse ST changes with no significant findings. Post-procedure, she developed chest and right shoulder pain and right-hand claudication. She had a normal exam with exception of diminished right brachial and radial pulse. CT angiogram revealed a proximal right subclavian artery (RSA) pseudoaneurysm at the innominate artery bifurcation along with bovine arch anatomy. PLAN: She was initially managed conservatively but presented at our emergency room with worsening symptoms at 2 weeks. Repeat CTA confirmed 1.1x1.7 cm right subclavian pseudoaneurysm. Treatment options of median sternotomy, TEVAR and hybrid repair were discussed. Hybrid approach was chosen as it was less invasive. She first underwent RSA debranching with right common carotid to right subclavian bypass. Right brachial access was used to perform retrograde innominate-common carotid artery stenting as well as coil embolization of the proximal RSA while preserving right vertebral artery antegrade flow. An 8 mm GORE VIABAHNŽ balloon expandable stent was used and was post-dilated to 13 mm in the innominate artery segment to obtain proximal and distal seal in proximal right common carotid, leading to successful exclusion of the subclavian pseudoaneurysm. Right femoral arterial access was also used to maintain access in the left common carotid artery as a bailout in case of inadvertent coverage. The patient did well and was discharged on postoperative day 2. She is free of symptoms at 8 months with complete resolution of the RSAA. pseudoaneurysm.DISCUSSION: Supra-aortic trunk aneurysms with a bovine arch anatomy add to the complexity of repair. This case represents a novel application of the VIABAHN balloon expandable stent graft for hybrid repair of a complex RSA aneurysm with bovine arch anatomy. This stent allowed for adequate seal in a relatively short proximal landing zone, with preservation of the left common carotid artery due to accurate deployment and ability to tailor the stent to the changing diameter of the vessel. 
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