Robotic-Assisted Ligation of the Aberrant Right Subclavian Artery for Dysphagia Lusoria

The patient was a 27-year-old female with a history of postural orthostatic tachycardia syndrome and Ehlers Danlos syndrome who presented with dysphagia to solids since 2021. Her work up was negative for esophageal dysmotility and gastroparesis. She had previously developed non-ischemic angina and underwent computed tomography, which identified an aberrant right subclavian artery and 1.5cm diverticulum of Kommerrell. An esophagram showed obstructive narrowing of the posterior esophagus superior to the aortic arch. Based on the diagnosis of dysphagia lusoria, operative intervention was pursued. 
 
To remove the entire aberrant right subclavian artery from the retro-esophageal space, a left-sided transthoracic robotic-assisted resection was performed using the DaVinci robotic system. Double lumen intubation for single-lung ventilation was used, and a right radial arterial line was placed to ensure adequate perfusion of the right upper extremity. The patient was positioned in the right lateral decubitus position, and the left chest was accessed through four robotic ports in the 5th and 6th intercostal spaces, with an assistant port in the 7th intercostal space. The mediastinal pleura above the aortic arch was incised, and the hemi-azygos was ligated as it was overlying the aberrant right subclavian artery. The phrenic and left recurrent laryngeal nerves were not encountered. The aberrant right subclavian artery was then encircled with a vessel loop and ligated off the aortic arch using a 30mm vascular stapler with the vessel loop for traction. The aberrant right subclavian artery was then mobilized from the esophagus and the posterior mediastinum, and a Blake drain was placed in the left pleural cavity. 
 
The patient was then turned supine, a shoulder roll was placed, and the right arm was abducted 45 degrees. Through a supraclavicular incision between the heads of the sternocleidomastoid muscle, the pulseless aberrant right subclavian artery was found to be nearly mobilized in its entirety. This allowed for an expeditious aberrant right subclavian artery transposition onto the right common carotid artery in an end-to-side fashion. There was no change in near-infrared spectroscopy monitoring during carotid clamping, and a palpable right radial pulse was noted. A Jackson-Pratt drain was left in the supraclavicular exposure. 
 
The patient had an uneventful hospitalization. Her dysphagia resolved postoperatively, and her chest tube and JP drain were removed after there was no chylous output on postoperative days 1 and 2, respectively. She had transient postoperative Horner’s syndrome, but was discharged home on postoperative day 3. At the three-month follow-up, her chest pain continued to improve. A six-month follow-up MRA showed a patent aberrant right subclavian artery transposition to the CCA and intact staple line. 
 
Prior case series used a right-sided approach and staged resection after carotid-subclavian bypass. In contrast the surgeons in this cased used a left-sided approach, which allowed for a flush division of the aberrant right subclavian, and combined with mediastinal mobilization, facilitated removal of the entire vessel from the retroesophageal space. Given the previous mediastinal mobilization, subsequent transposition is expeditious and facilitates a single operative visit. This approach requires a single anastomosis and avoids a prosthetic bypass. The described technique is a novel, minimally invasive approach to dysphagia lusoria. 

References

1. Tallarita T, Rogers RT, Bower TC, et al. Characterization and surgical management of aberrant subclavian arteries. J Vasc Surg. 2023;77(4):1006-1015. doi:10.1016/j.jvs.2022.12.018
2. Meredith LT, Isch EL, Ali MI, Nooromid MJ, Okusanya OT. Technical considerations in robotic aberrant right subclavian artery resection for dysphagia lusoria. J Vasc Surg Cases Innov Tech. 2024;10(4):101525. Published 2024 May 9. doi:10.1016/j.jvscit.2024.101525
3. La Regina D, Prouse G, Mongelli F, Pini R. Two-step treatment of dysphagia lusoria: robotic-assisted resection of aberrant right subclavian artery following aortic debranching. Eur J Cardiothorac Surg. 2020;58(5):1093-1094. doi:10.1093/ejcts/ezaa182

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