Aberrant Right Subclavian Artery Translocation

An aberrant right subclavian artery is the most common embryological abnormality of the aortic arch and is known clinically as arteria lusoria. In the case of this patient, there was complete absence of the brachiocephalic trunk and the right subclavian was seen branching distal or to the left of the left subclavian artery. To supply blood to the right upper extremity, the vessel must travel across the body’s midline, most commonly passing posterior to the esophagus. Dysphagia lusoria is the result of esophageal compression by the aberrant vessel.

A number of surgical techniques have previously been described for surgical management of an aberrant right subclavian artery, including both right and left thoracotomies, median sternotomies, or combined approaches.

The patient presented in this video is an eighteen-year-old woman with complaints of severe dysphagia since childhood. To eat, she often had to cut up her food into very small pieces. Her medical comorbidities include Ehlers Danlos syndrome. A barium study revealed compression of the posterior esophageal wall at the level of the arteria lusoria.

The patient was brought to the cardiac operating room for surgical correction. She was placed in a supine position with a roll under her shoulder and her head turned to the left. An orogastric tube was placed to help identify the esophagus during the dissection.

To begin, a transverse supraclavicular incision was made on the right anterior neck. The platysma was divided and the clavicular head of the sternocleidomastoid was retracted laterally. A plane was created laterally between the carotid sheath and medially between the trachea and esophagus. Dissection was carried down deep and medial to the right carotid artery. The apical pleura was then reflected. The aberrant right subclavian artery was visualized coursing posterior to the esophagus.

Dissection was carried out as far as possible beyond the left side of the esophagus. This was critical to enable the divided origin stump to retract in the left chest and prevent residual compression effect in its proximal course. The right subclavian artery was then ligated, clipped, and divided. Further mobilization was done as far as possible to allow for complete retraction of the stump of the subclavian artery.

Attention was then brought to the right common carotid artery. The vessel was dissected and occluded with a C-clamp and a vertical arteriotomy was tailored to the size of the right subclavian artery. The peripheral end of the aberrant right subclavian artery was then anastomosed to the right common carotid artery in an end-to-side fashion using continuous Prolene sutures. Once the anastomosis was complete, the clamps were removed and good pulsations were seen in the reimplanted vessel. The remainder of the operation was completed in a routine fashion.

The patient made an excellent recovery and was discharged home the next day. She had an immediate relief of her dysphagia and the next morning, for the first time in her life, she was able to eat a steak and french fries without having to chop them up into smaller pieces. At two years follow up, she remained without dysphagia and she had normal pulses and blood pressure in her right upper extremity.

To conclude, surgical management of dysphagia lusoria can be successfully performed through a single cervical incision. Relief of dysphagia and preservation of the right subclavian artery can be accomplished without the need for multiple incisions or more extensive approaches via sternotomy or thoracotomy. The cervical approach offers less postoperative pain, shorter length of stay, and overall fewer complications. For non-aneurysmal disease, a single cervical incision is a less invasive approach and provides similar outcomes.

References

1. Polguj, M., Chrzanowski, Ł., Kasprzak, J. D., Stefańczyk, L., Topol, M., & Majos, A. (2014). The aberrant right subclavian artery (Arteria Lusoria): The morphological and clinical aspects of one of the most important variations—A systematic study of 141 reports. The Scientific World Journal, 2014, 1–6. https://doi.org/10.1155/2014/292734
2. Taylor, M., Harris, K. A., Casson, A. G., DeRose, G., & Jamieson, W. G. (1996). Dysphagia lusoria: extrathoracic surgical management . Canadian Journal of Surgery, 39(1), 48–52. https://www.canjsurg.ca/content/39/1/48.long
3. Nelson, J. S., Hurtado, C. G., & Wearden, P. D. (2020). Surgery for Dysphagia Lusoria in Children. The Annals of Thoracic Surgery, 109(2), e131–e133. https://doi.org/10.1016/j.athoracsur.2019.05.058

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