Repair of Thoracic Aortic Aneurysm with Right Aberrant Subclavian Artery and Anomalous Origin of Left Subclavian Artery

P0285 

Abstract Submission 

Yuki Ikeno (1), Francesco Brandini (1), Lucas Ribe (1), Anthony Estrera (1), Akiko Tanaka (1)

(1) McGovern Medical School at UTHealth, Houston, TX

Yuki Ikeno    -  Contact Me
McGovern Medical School at UTHealth

Francesco Brandini    -  Contact Me
McGovern Medical School at UTHealth

Lucas Ribe    -  Contact Me
McGovern Medical School at UTHealth

*Anthony Estrera    -  Contact Me
McGovern Medical School at UTHealth

Akiko Tanaka    -  Contact Me
McGovern Medical School at UTHealth

Yuki Ikeno    -  Contact Me
McGovern Medical School at UTHealth

Objective:
Aberrant subclavian artery is a rare congenital anomaly of the aortic arch, with reported incidence of left aortic arch with aberrant right subclavian artery (ARSA) in 0.7 to 2.0% of the population. Furthermore, the anomalous origin of left subclavian artery (AOLSA) in a left aortic arch is an extremely rare anomaly that only a few cases have been previously reported. This report details the successful surgical repair of an exceptionally uncommon case: a descending thoracic aortic aneurysm coinciding with a ARSA and an AOLSA, accompanied by a Kommerell's diverticulum.

Methods:
A 19-year-old female with no significant past medical history presented outside hospital with episodic chest and back pain. Computed tomography angiography (CTA) revealed an aneurysmal dilation extending from the distal arch to the proximal descending thoracic aorta, with a maximum diameter of 41 mm. Notably, the CTA also identified unique anatomical variations in the aortic arch: both right and left subclavian arteries originated anomalously from the proximal descending aorta.

Results:
Femorofemoral cardiopulmonary bypass was initiated for deep hypothermic circulatory arrest, aiming nasopharyngeal temperature of 20 °C. The thoracic aorta was clamped at the level of T6. The proximal descending aorta was opened and replaced with a branched 18-mm woven Dacron graft. Three separate 8-mm side-branches were hand-sewn to the main body before initiating cardiopulmonary bypass, and fashioned for reconstructions of bilateral subclavian arteries as well as arterial cannulation. The proximal anastomosis was constructed just distal to the left common carotid artery. The right subclavian artery was reconstructed to the second side-arm prior to the distal anastomosis. The 8-mm graft was anastomosed to a healthy portion of the ARSA to exclude the aneurysmal segment using inclusion technique. The distal anastomosis was then performed at the level of the T5. The AOLSA was bypassed with the last 8-mm Dacron graft. The circulatory arrest time was 22 minutes for proximal, and cardiopulmonary bypass time was 129 minutes. Postoperative course was complicated with chylothorax, which reslolved with low-fat diet. She was discharged at postoperative day 14th.
The pathology reported that aortic tissue has focal fibrocellular intimal thickening, dense adventitial fibrosis, and severe near-complete loss of medial elastic fibers on elastic stains, consistent with Kommerell's diverticulum.

Conclusion:
We presented a case of an extremely rare anatomical configuration comprised of an ARSA in left aortic arch, in the presence of Kommerell's diverticulum, an AOLSA and a descending thoracic aortic aneurysm. Open aneurysm repair with in situ reconstruction of subclavian arteries was satisfactory.

Aortic Surgery Forum (Basic Aortic Research, Venue for Residents, Fellows, Junior Attendings)