Current Approach To Aberrant Subclavian Artery Operative Management In The Setting Of Concomitant Aortic Pathology
Anastasia Plotkin, MD, Sukgu M. Han, MD, MS, Fred A. Weaver, MD, MMM, Robbin G. Cohen, MD, Michael E. Bowdish, MD, Gregory A. Magee, MD, MSc.
University of Southern California, Los Angeles, CA, USA.
OBJECTIVES: Aberrant subclavian artery (aSCA) is a rare anomaly that has traditionally been repaired for compressive symptoms or large Kommerell’s diverticulum (KD). Repair techniques continue to evolve with increased hybrid and total endovascular approaches. This study aims to evaluate the outcomes of different operative techniques and describe the various aortic pathology and symptoms that drive the decision for operative repair.
METHODS: Single-center institutional database was queried for patients with aSCA who underwent operative repair from 2006-2018. Primary outcomes were type of repair, postoperative complications, and in-hospital mortality. Secondary evaluations included preoperative symptoms, aortic pathology (aneurysm or dissection), and aSCA characteristics.
RESULTS: Of 53 patients with aSCA undergoing a cardiovascular operation, 18 had aSCA repair (50% men, average age 54 years). aSCA was right-sided in 15 (83%), associated with a KD in 15 (83%, average size 2.1 cm), and all were retroesophageal. Seventeen were symptomatic: dysphagia (12, 67%), reflux (10, 56%), chest pain (6, 33%), asthma (5, 28%), and hoarseness (2, 11%). Indications for intervention were symptoms (9, 50%), aortic pathology (8, 44%), and coronary artery disease (1, 6%). Operations were hybrid (11, 61%), open repair (6, 33%), and total endovascular repair (EVR, 1, 6%). Hybrid repair involved carotid subclavian/axillary bypass (10, 91%) or transposition (1, 9%) with TEVAR. In open repair, KD was excluded by aortic graft placement (3, 50%) or over-sewing (2, 33%), in conjunction with carotid subclavian bypass (1, 17%), transposition (2, 33%), or ascending aorta-subclavian bypass (3, 50%). The EVR consisted of fenestrated TEVAR and aSCA stent. Minor complications (lymphatic leak, hematoma, acute kidney injury, urinary tract infection) occurred in 5 hybrid patients (45%), 2 open (33%), and the EVR. Major complications (respiratory, stroke, paraplegia) occurred in 2 hybrid patients (18%), 1 open (17%), and the EVR. Four patients repaired for aortic pathology had major complications (50%), one patient repaired for aSCA-associated symptoms had major complications (11%). In-hospital mortality was 17%: 2 (18%) in the hybrid and 1 (17%) in the open group, all were repaired for aortic pathology.
CONCLUSIONS: Despite advances in endovascular therapy allowing for simultaneous and staged treatment of aSCA with concomitant complex aortic pathology the complication rates are similar between open, hybrid, and total endovascular repair.
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