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A fifteen-year-old girl (BMI 16.4 kg/m) with a two-year history of dysphagia, periprandial angina, and anorexia was referred to pediatric general surgery. A contrast swallow demonstrated a luminal obstruction to the esophagus, but the cause was not visible with this modality. Therefore, the patient underwent a CT scan of the thorax and abdomen, which revealed a right subclavian artery (RSA) of anomalous origin from the distal thoracic aorta (DTA). The patient was referred to pediatric cardiac surgery and consented for correction.
To begin, an anterolateral thoracotomy in the fourth intercostal space was performed. Then, the mesenchyme was dissected and the viscera mobilized until the RSA was identified and mobilized with diathermy to the surrounding connective tissue, and until the anomalous origin could be visualized at the DTA. A right-angle clamp was used to introduce a vessel loop around the RSA, which allowed for control and subsequent identification.
Next, the right jugular vein was identified in the correct anatomical position. This signified an anatomical landmark for the right carotid artery (RCA). The mesenchyme was then carefully dissected before the RCA could be visualized and mobilized. A vessel loop was introduced as previously described. A c-clamp was used to temporarily divide a sagittal section of the RCA wall; this is the anastomotic site. The site was then tested for robustness and durability and the clamp was removed.
After this, the RSA was clamped using a right-angle at the anomalous origin. A transecting incision was made to the RSA distal to the clamp, and the remaining stump at the origin was oversewn using 6-0 Prolene. Before removing the clamp, the surgeon had to ensure that any anastomotic leak had been addressed and that full hemostasis had been achieved. This is because the stump moves medially upon declamping, and any subsequent bleeding would be difficulty to localize and control. The arterial pressure of the right upper limb significantly deteriorated upon clamping of the RSA, suggesting anastomosis of the RSA to the RCA was indicated.
Finally, a c-clamp was reapplied to the anastomotic site of the RCA. The free RSA was then grafted onto the RCA in end-to-side anastomosis using a 6-0 Prolene. After checking for anastomotic leak and achieving hemostasis, the c-clamp was removed and the anastomosis was functional. The arterial pressure in the right upper limb normalized.
The patient was then closed and transferred to ICU before being discharged following convalescence. They remain asymptomatic.
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3 Comments
Thanks, seems straightforward. How did you go about heparinisstion?
This video by Drs. Reynolds, Fittipaldi, Skerritt and Caputo is a video demonstration of the technique of anterior lateral thoracotomy and division of an aberrant right subclavian artery and transposition to the right common carotid artery (1). The ease of the operation was aided by the patient’s BMI=16.4. Open treatment may be more difficult in adult or larger patients but offers the advantage of immediate revascularization of the right subclavian artery.
Restoring pulsatile blood flow to the right arm has been debated. Some advocate that revascularizing the subclavian artery is imperative (2). A published review demonstrated only 14% of patients who did not undergo revascularization following surgical treatment of anomalous right subclavian artery developed limb ischemia (3). A case report demonstrated a patient did well without revascularization with intermittent weakness and numbness of his right arm until his death 11 years later (4).
We previously demonstrated on CTSNet a minimally invasive robotic approach to divide the aberrant right subclavian artery without revascularization (5). The robotic approach has also been described elsewhere but as a two stage treatment (6). Our patient was discharged home on the 1st postoperative day and had quick recovery. The patient did require revascularization 1 year later due to right arm fatigue. A carotid to subclavian bypass was easily performed with resolution of symptoms. Our subsequent patients have not required revascularization.
The authors are to be commended for an excellent demonstration of an open approach with a good result.
References
1. Reynolds A, Fittipaldi M, Skerritt C, Caputo M. Correction of Anomalous Origin of Right Subclavian Artery from Distal Thoracic Aorta. November 2022. doi:10.25373/ctsnet.21585924.v1
2. Jalaie H, Grommes J, Sailes A, et al. Treatment of symptomatic aberrant subclavian arteries. European Vac Endovasc Surg 2014; 48:521-26.
3. Knight GC, Codd JE. Anomalous right subclavian artery aneurysms. Report of 3 cases, with a review of the literature. Tex Heart Inst J 1991; 18:209-18.
4. Saeed G, Ganster G. Arteria lusoria aneurysm with truncus bicaroticus. Surgical resection without restoring blood supply to the right arm. Tex Heart Inst J 2010; 37:602-607.
5. Jett GK, Hafen L, Tran A, Shutze W. Robotic Assisted Treatment of Aberrant Retroesophageal Right Subclavian Artery. April 2021. doi:10.25373/ctsnet.14465859
6. Regina DL, Prouse G, 1 Mongelli F, at all. Two-step treatment of dysphagia lusoria: robotic-assisted resection of aberrant right subclavian artery following aortic debranching. European J Cardio-Thoracic Surg 2020; 58: 1093-1094.
Dear Dr Jett
Thanks for your very useful and interesting comments.
Can I ask you what you would do for a 5 year old girl with the same anatomy but only 50% oesophageal compression (described as mild) and mild symptoms? Just seen the data at joint meetings and there was no consensus about treatment
Thanks