Total endovascular repair of aberrant right subclavian artery aneurysm using the periscope technique: a case report

Hybrid management of aberrant subclavian artery: A systematic review and meta-analysis

OBJECTIVE

To elucidate the short- and long-term mortality, morbidity, and endoleak incidences in the hybrid management of aberrant subclavian artery (ASA).

METHODS

A systematic review and meta-analysis of 99 articles comprising n = 272 cases using PRISMA were supplemented by Cohen's Kappa for assessor consistency. The analysis involved a random-effect model, odds ratios (ORs) with 95% confidence intervals, tests of heterogeneity, and probability. This review was registered with the International Prospective Register of Systematic Reviews (CRD42023405011).

RESULTS

The 30-day mortality was 4.6% (95% CI: 1.4%-14.4%) with an overall mortality of 7.3% (95% CI: 2.9%-18.7%) demonstrating a 1.2% increase in mortality per decade of life beyond 60 years. The reported morbidity was 7.6% (95% CI: 3.7%-15.7%) and higher in males albeit higher age (p < .05) (67 vs 59 years). The endoleak incidence stood at 7.8% (95% CI: 3.3%-18.3%) with Type-I the as prominent (48%). Rupture presentation was in 3%, whilst esophageal fistulation (n = 2/3) was associated with morbidity of 66%. Treatment varied, with TEVAR and carotid-subclavian bypass being the most common modality of the choice. The median follow-up was 12 months (IQR, 1-60 months).

CONCLUSION

The observed incidence of mortality, morbidity, and endoleak shows the current role of the hybrid approach in managing ASA. These results emphasize the critical role of detailed surgical planning, combined endovascular and open expertise, and the necessity for a common registry to monitor long-term outcomes.

Thoracic endovascular aortic repair for type B aortic dissection with aberrant right subclavian artery: a single-center retrospective study

Objective

To evaluate the outcomes of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) with aberrant right subclavian artery (ARSA).

Methods

A retrospective analysis was conducted on patients with TBAD and ARSA who underwent TEVAR between the period of January 2017 and December 2022. Patient demographics, computed tomography angiography (CTA) measurements, surgical procedures, and postoperative outcomes were reviewed.

Results

A total of 9 patients (6 males and 3 females) were included in the study. 4 ARSA were reconstructed, 3 by periscope technique and 1 by in vitro fenestration technique. 3 left subclavian arteries (LSA) were reconstructed, 1 by the chimney technique and 2 by the single-branched stent technique. 2 patients underwent reconstruction of both ARSA and LSA. The overall technical success rate was 100%, with no occurrences of stroke, paraplegia, or mortality within 30 days. 1 patient experienced immediate type Ia endoleak, which resolved after 3 months. 1 patient developed weakness in the right upper limb, while 1 patient presented mild subclavian steal syndrome (SSS); both cases showed recovery during follow-up. The average follow-up duration was 35.6 ± 11.1 months, during which no reinterventions, deaths, or strokes were observed.

Conclusion

Our limited experience involving 9 patients demonstrates that early and mid-term outcomes of TEVAR for the treatment of TBAD with ARSA are satisfactory.

Characterization and surgical management of aberrant subclavian arteries

OBJECTIVE

Aberrant subclavian arteries (aSCAs), with or without aortic pathology, are uncommon. The purpose of the present study was to review our experience with the surgical management of aSCA.

METHODS

We performed a retrospective review of patients who had undergone surgery for an aSCA between 1996 and 2020. Symptomatic and asymptomatic patients were included. The primary end points were ≤30-day and late mortality. The secondary end points were ≤30-day complications, graft patency, and reinterventions.

RESULTS

A total of 46 symptomatic and 3 asymptomatic patients with aSCA had undergone surgery (31 females [62%]; median age, 45 years). An aberrant right subclavian artery was present in 38 (78%) and an aberrant left subclavian artery in 11 patients (22%). Of the 49 patients, 41 (84%) had had a Kommerell diverticulum (KD) and 11 (22%) had had a concomitant distal arch or proximal descending thoracic aortic aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia (20%), and upper extremity exertional fatigue (16%). Five patients (10%) had required emergency surgery. The aSCA had been treated by transposition in 32, a carotid to subclavian bypass in 11, and an ascending aorta to subclavian bypass in 6. The KD was treated by resection and oversewing in 19 patients (39%). Fifteen patients (31%) had required distal arch or proximal descending thoracic aortic replacement for concomitant aortic disease and/or KD treatment. Thoracic endovascular aortic repair was used to exclude the KD in six patients (12%). Seven patients (14%) had undergone only bypass or transposition. The 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. The 30-day major complications (14%) included acute respiratory failure in three, early mortality in one, stroke in one, non-ST-elevation myocardial infarction in one, and temporary dialysis in one patient. The other complications included chylothorax/lymphocele (n = 5; 10%), acute kidney injury (n = 2; 4%), pneumonia (n = 2; 4%), wound infection (n = 2; 4%), atrial fibrillation (n = 2; 4%), Horner syndrome (n = 2; 4%), lower extremity acute limb ischemia (n = 1; 2%), and left recurrent laryngeal nerve injury (n = 1; 2%). At a median follow-up of 53 months (range, 1-230 months), 40 patients (82%) had had complete symptom relief and 9 (18%) had experienced improvement. Six patients had died at a median of 157 months; the deaths were not procedure or aortic related. The primary patency was 98%. Reintervention at ≤30 days had been required for two patients (4%) for ligation of lymphatic vessels and bilateral lower extremity fasciotomy after proximal descending thoracic aorta replacement. One patient had required late explantation of an infected and occluded carotid to subclavian bypass graft, which was treated by cryopreserved allograft replacement.

CONCLUSIONS

Surgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief.

Asymptomatic Giant Aneurysm of the Arteria Lusoria Treated by Debranching and Aneurysmal Resection

The aberrant right subclavian artery (ARSA, arteria lusoria) is the most common intrathoracic vascular anomaly, affecting up to 2% of the population. However, aneurysms of congenital anomalies are extremely unusual and often present with dysphagia, dysphonia, or dyspnea due to compression of the surrounding structures. We report a case of an asymptomatic 57-year-old male with chronic kidney disease who was incidentally found to have a large aneurysm of the ARSA on preoperative computed tomography for laparoscopic nephrectomy. Surgery is unequivocally warranted as these aneurysms are associated with a high risk of complications, including thrombosis, embolism, and rupture. We debranched the ARSA, followed by anastomosis to the right carotid artery through a right neck incision. Subsequently, aneurysmal resection was performed through left thoracotomy. The patient had an uneventful postoperative recovery and was asymptomatic during the follow-up.

Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.

Arteria lusoria dissection with mediastinal hematoma as a complication of a transradial coronary catheterization: Case report and literature review

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Aberrant right subclavian artery (ARSA), or arteria lusoria is the most common embrologic anomaly of the aortic arch.

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The ARSA arises after the origin of the left subclavian artery and then reaches the posterior mediastinum.

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The presence of ARSA is generally asymptomatic, but may cause complications, during some endovascular procedures.

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Prompt diagnosis and treatment is required to avoid more dreadful complications.

Introduction

Aberrant right subclavian artery (ARSA), or arteria lusoria is the most common embrologic anomaly of the aortic arch. It is generally asymptomatic and incidentally diagnosed during a radiological exam or procedure.

Presentation of case

Here, we report a case of ARSA incidentally diagnosed and injured (dissection with mediastinal hematoma) during a right transradial coronary angiography in a 83 years old female patient. The patient underwent prompt hybrid procedure with the isolation of the right humeral artery from where we positioned a GORE® VIABAHN® 9 × 100 mm endoprosthesis. The procedure was successful with optimal results at early and long term follow up.

Discussion

Sometimes, a dissection of the ARSA may occur, especially for excessive manipulation during endovascular procedures, and when such complication happens it should be promptly treated as it can be life-threatening.

Conclusion

If transradial catheterization during coronary angiography becomes particularly difficult, requires longer time, or the guide wire enters in the descending aorta, particularly attention should be paid, as dreadful complications such as dissection or lesion may happen and prompt treatment is required.

Single-stage total endovascular therapy for an aberrant right subclavian aneurysm

A 34-year-old woman who demonstrated an aberrant right subclavian artery aneurysm was referred to our hospital. Single-stage total endovascular therapy with preservation of the right vertebral artery using a surgeon-modified fenestrated stent graft was performed. Contrast-enhanced computed tomography on postoperative day 4 revealed the patency of the right vertebral artery with no evidence of endoleaks. The patient was discharged on postoperative day 6. Three years later, the patient had no adverse events. When an aberrant right subclavian artery aneurysm is anatomically suitable, single-stage total endovascular therapy for such an aneurysm is considered to be a feasible and appropriate minimally invasive treatment.

Aberrant right subclavian artery (arteria lusoria) aneurysm with a Kommerell's diverticulum

The treatment options for aberrant right subclavian artery vary depending on the presence of Kommerell’s diverticulum. Because there is a tendency not to report mortalities of these rare cases in the literature, it is hard to reach a conclusion on treatments from the limited data on post-interventional results in these patients. We report our experience with a 67-year old patient with an aberrant right subclavian aneurysm with Kommerell’s diverticulum, diagnosed by chance.