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Anomalous Left Carotid Vertebral Artery Transposition During Hybrid Repair For Dysphagia Lusoria
Imani E. McElroy, MD MPH1, Gregory Magee, MD
2.
1University of Southern California, Los Angeles, CA, USA,
2New York University, New York City, NY, USA.
We present the technique for transposition of anomalous left vertebral (aLVA) to left carotid artery during a hybrid repair for dysphagia lusoria. Surgical intervention remains the primary treatment option. The patient is a 52 year old male with history of severe dysphagia and complete GI work up only finding compression of the proximal esophagus so the diagnosis of dysphagia lusoria was made. On CT, he was found to have an aLVA arising directly from the aortic arch, which was the dominant vertebral artery. The incision and exposure start the same as for a subclavian transposition. A supraclavicular incision is made, subplatysmal flaps are raised, and the heads of the sternocleidomastoid muscle are split to expose the carotid sheath. The common carotid artery is exposed, and the posterior carotid sheath is opened to expose the deep cervical/prevertebral fascia, which is then opened, and the aLVA is located. Unlike the conventional vertebral anatomy, the aLVA often enters the vertebral canal at c5 or c4, which enables exposure directly posterior to the carotid. We recommend avoiding exposing the aLVA at the aortic arch itself as this has been associated with high rates of recurrent laryngeal nerve injury. The vertebral artery is invested in the cervical sympathetic plexus, so care must be taken to avoid injury to the surrounding nerves. We identify the cervical plexus and gently mobilize it to expose the vertebral artery more proximally. The vertebral artery is then clamped distally with a bulldog clamp, ligated and divided proximally, and passed through the investing sympathetic plexus to allow for enough length to align it with the common carotid artery for transposition. The common carotid is then clamped proximally and distally. An 11-blade is used to make an arteriotomy in the carotid artery, which is then widened with an aortic punch. The vertebral artery is beveled before performing an end-to-side anastomosis. Upon completion of the anastomosis, the clamps are removed, and patency is confirmed with Doppler. The remaining portions of the hybrid repair were performed, including zone 2 TBE and right subclavian transposition. The postoperative CTA reconstruction demonstrates patency of the aLVA transposition and no endoleak. Key takeaways from this case show that vertebral carotid transposition can be performed without much added time or morbidity to subclavian transposition.
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