Yasui Procedure with Aberrant Right Subclavian Artery Translocation

This video demonstrates Dr. James Tweddell's surgical strategy in a two-month-old male with diagnosis of aortic atresia, hypoplastic aortic arch, coarctation, large perimembranous VSD, mildly hypoplastic mitral valve, normal biventricular size, and bilateral SVC (left SVC to CS). There was also an intraoperative finding of an aberrant right subclavian artery originating from the descending thoracic aorta with retroesophageal course.

To begin, the patient was palliated in the neonatal period with branch pulmonary artery banding (PAB). Ductal patency was then maintained with a prostaglandin infusion through to definitive surgical repair date. 

A redo median sternotomy and extensive dissection was then performed. The ascending aorta was 2mm in diameter. There was an anomalous origin of the right subclavian artery from the proximal descending thoracic aorta. The right carotid artery was isolated and anastomosed to a Gore-Tex tube graft. The graft, LSVC, and IVC were cannulated, and CPB was initiated. 

Next, antegrade cerebral perfusion was initiated. Then, the graft was sewn onto the carotid artery distally enough so that the proximal carotid could have the right subclavian artery reimplanted into it. The anomalous right subclavian artery was ligated at its origin with Prolene sutures and divided distally to the ligature. It was mobilized from behind the esophagus and trachea. The proximal carotid artery was incised longitudinally along the inferior aspect, and the subclavian artery was then anastomosed to the carotid artery in an end-to-side fashion. 

After this, the branch PAB was de-banded and gently dilated, thus not requiring patch augmentation. 

The ductus was divided next. The isthmus was not divided due to absence of a posterior shelf. The descending aorta was mobilized, and the first three sets of intercostal branches were taken. The incision was then completed from the divided ductus and continued along the underside of the aortic arch and lateral ascending aorta. A cutback was made to the left of facing commissure in the pulmonary root. Then, Damus-Kaye-Stansel was performed, the edge of the thoracic aorta and left lateral ascending aorta were joined together, and the anterior arch was reconstructed with a pulmonary homograft.  

Next, the secundum ASD was closed, and a ventriculotomy was performed in the right ventricular free wall and enlarged to 15mm. The VSD was enlarged superiorly and anteriorly. Pledget-supported sutures were then placed along inferior rim avoiding injury to the tricuspid valve and conduction system. The ends of the rows were run continuously to complete a baffle. A bovine pericardium was used to create a LV-to-aorta baffle. 

Finally, RVOT was reconstructed with 11mm pulmonary homograft with the anterior hood of a bovine pericardium for proximal securement of the conduit to ventriculotomy. 

Echo showed good biventricular function with no residual VSD or ASD. However, there was trivial left and right AV valve regurgitation. There was no LVOTO or obstruction through the RV-to-PA conduit. 

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.