Aberrant Right Subclavian Artery Treated With Right Cervical Debranching And Left Subclavian Artery In-Situ Laser Fenestrated TEVAR
Jonathan Parker, BS, Nolan Mann, MD, Karam Obeid, BS, Michael Pham, MS, Samer Alharthi, MD MPH, David Dexter, MD, Jean Panneton, MD, Animesh Rathore, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
DEMOGRAPHICS: 60-year-old African American female
HISTORY: She presented with dysphagia to solid foods, hoarseness, neck stiffness, and ten-pound weight loss over three months. Chest CT angiogram demonstrated a bi-carotid trunk and aberrant right subclavian artery (ARSA) with a Kommerell diverticulum compressing the esophagus confirming dysphagia.
PLAN: Multi-disciplinary team reviewed the options which include open repair with medial sternotomy versus left thoracotomy or hybrid approaches with debranching of the great vessels then thoracic endovascular aortic repair (TEVAR). Based on the anatomy and patient comorbidities, we decided to do a hybrid approach. There was a short landing zone (4.2mm) between the aberrant right subclavian and left subclavian origins which necessitate a proximal (zone 2) seal requiring coverage of the left subclavian artery (LSA), hence LSA revascularization. Through a longitudinal incision along the sternocleidomastoid’s anterior border, we performed an ARSA to right common carotid artery transposition along with ligation of the proximal stump of the Kommerell diverticulum. Zone 2 TEVAR was then performed with 31mm x 31mm x 90mm Navion endograft through retrograde bilateral femoral access, covering the LSA origin. The left subclavian revascularization was performed by a retrograde in-situ laser fenestration technique. A 2.3mm Excimer laser fiber was used from left brachial access to create a fenestration followed by 6mm balloon angioplasty of the fenestration. Subsequent stenting was completed with a 10mm x 38mm iCAST covered stent which was post-dilated. Completion angiogram showed successful exclusion of the Kommerell’s diverticulum, no endoleaks, good apposition of the graft, and filling of all the arch vessels. Postop course was uneventful. She was discharged home on post-op day two. Four months post-op, her dysphagia symptoms have completely resolved and CT shows widely patent transposed ARSA, LSA fenestration, and regressed Kommerell diverticulum.
DISCUSSION: Management of ARSA with dysphagia lusoria has shifted away from technically challenging sternotomy or thoracotomy approaches due to potentially high morbidity and mortality. The conventional hybrid option includes bilateral subclavian debranching with TEVAR. The technique described a novel application of retrograde in-situ laser fenestration, which allowed us to avoid a left neck incision. Most notably, this technique will potentially reduce the associated complications of phrenic nerve injury, chyle leak, recurrent laryngeal nerve palsy, bleeding requiring re-intervention, and axillary nerve palsy acquired from the secondary bypass/transposition and concomitant incision.
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