Total Arch Replacement for a Distal Aortic Arch Aneurysm With Right Aortic Arch

Single-Stage Total Arch Replacement With Open Stent Graft for Kommerell's Diverticulum With Right-Sided Aortic Arch

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

A review of the surgical management of right-sided aortic arch aneurysms

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques.

Video assisted thoracoscopic surgery cases with right-sided aortic arch aneurysm and complete vascular ring: Case report

•

Think of vascular ring when facing an infant with vomiting after feeding, stridor, high pitched and brassy cough, noisy respiration, emesis and respiratory distress.

•

Use of CT angiography, MRI and barium swallow to evaluate vascular ring and its type.

•

Video assisted thoracoscopic surgery (VATS) is a feasible procedure for sectioning the right-sided aortic arch by the use of clips.

Introduction

Right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum, after double aortic arch, is the second most common complete vascular ring. It was traditionally treated by open surgical thoracotomy and recently video assisted thoracoscopic surgery (VATS) has been used in some cases.

Presentation of case

We describe the cases of two infants who presented with gastroesophageal reflux, dyspnea, dysphagia secondary to aneurysmal dilatation of the retroesophageal arch confirmed by imaging data. VATS procedure was performed through a left thoracoscopic approach. Ligamentum arteriosus compressed esophagus was clipped, sectioned and then released the esophagus in one case; also, In the second case, we clipped and sectioned aorta, distal to the origin of aberrant left subclavian artery.

Discussion

CT angiography and MRI are known to be the most effective available imaging methods for vascular ring detection. Also, there are several surgical approaches to vascular rings such as, thoracotomy and thoracoscopy. There is a large body of evidence confirming the safety, efficacy and convenience of VATS as a therapeutic option for congenital heart disease including right-sided aortic arch and aberrant left subclavian artery.

Conclusion

VATS is a less invasive and safe strategy for management of right-sided aortic arch with aberrant left subclavian artery and ligamentum arteriosum.

Aortic arch replacement through a left thoracotomy for right-sided aortic arch aneurysm with complete vascular ring

Right-sided aortic arch with retroesophageal left subclavian artery and left ligamentum arteriosum is the second most common vascular ring. Aneurysms of the arch in its retroesophageal portion are rare. The surgical repair of a retroesophageal arch aneurysm poses a significant challenge because no single approach provides access to the whole arch and all of its branches. We describe a 39-year-old patient with aneurysmal dilatation of the retroesophageal arch who presented with airway obstruction. The arch aneurysm was repaired with a staged approach. A right-sided carotid-subclavian artery bypass was performed, followed by distal ascending aorta and aortic arch replacement under hypothermic circulatory arrest through a left thoracotomy.

Type A Aortic Dissection, Right-Sided Aortic Arch, and Thoracic Aortic Aneurysm

A previously healthy 78-year-old woman presented with severe chest pain. Computed tomography revealed a right-sided aortic arch with an aberrant left subclavian artery originating from Kommerell's diverticulum, a thoracic aortic aneurysm, and Stanford type A acute aortic dissection. Successful emergency repair of the ascending aorta, total arch, and descending aorta were performed through a median sternotomy only.

Multi-slice tomographic diagnosis of isolated right aortic arch in an elderly patient

Occasional report of asyntomatic right aortic arch in a 90-year-old man with any congenital defect associated.