CASE REPORT Open Access

Aberrant right subclavian artery re-routingfor hybrid repair of proximal descendingaortic aneurysmTae Yun Kim1* and Kyung Hwa Kim1,2*

Abstract

Background: An aberrant right subclavian artery (ARSA) is a relatively prevalent vascular anomaly. What is the mostappropriate treatment for thoracic aortic aneurysm combined a non-aneurysmal change ARSA?

Case presentation: A 52-year-old man was admitted to our institute due to a history of chronic cough, dysphagiaand an abnormal chest radiographic finding. Because of his progressive symptoms and large fusiform thoracicaneurysm, we performed the hybrid repair for simultaneous relief of an ARSA causing dysphagia and thoracicaneurysm.

Conclusion: In case without aneurysm of ARSA, especially in conjunction with approximate thoracic aneurysm, ourapproach is suitable because the revascularization using the right carotid to subclavian artery re-routing prior toendograft deployment is justified in order to preserve circulation of posterior brain, spinal cord, internal mammaryartery and upper limb and to prevent large retrograde type II endoleaks, as well as simplicity and durability.

Keywords: Aberrant right subclavian artery, Proximal descending aortic aneurysm

BackgroundAn aberrant right subclavian artery (ARSA) is arelatively prevalent vascular anomaly [1]. We consid-ered several treatment options for throracic aorticaneurysm combined non-aneurysmal formation ARSA.For example, there were the isolated open surgery forthoracic aneurysm due to relatively young age, or se-lective thoracic endograft for simplicity, or occlusionthe orifice of the aberrant right subclavian artery usingan vascular plug and added a carotid-subclavian by-pass / transposition via a supraclavicular incision. Inthe endovascular era, we presented the hybrid repairfor simultaneous relief of an ARSA causing dysphagiaand thoracic aneurysm.

Case presentationA 52-year-old man was admitted to our institute dueto a history of chronic cough, dysphagia and an

abnormal chest radiographic finding. A chest x-rayand computed tomographic angiography scan (CTA)revealed an ARSA behind the esophagus with about5.6-cm sized proximal descending aortic aneurysm(Fig. 1a). The esophagus was clearly compressed bythe ARSA (Fig. 1b), likely causing the dysphagia. Bothcarotid arteries had a common origin. Because of hisprogressive symptoms and large fusiform thoracicaneurysm, we planned the hybrid repair for simultan-eous relief of ARSA causing dysphagia and thoracicaneurysm. First, an ARSA to the right carotid arterytransposition with a proximal ligation of the ARSAalong distal to the right vertebral and mammary arter-ies was performed via the right supraclavicular inci-sion (Fig. 1c). One hour later, we performed a thoracicendovascular aortic repair (TEVAR), deploying of athoracic endovascular covered stent graft (Valiant™thoracic stent graft with the Captivia™ delivery system)in the descending thoracic aorta with the coverage ofthe origin of the ARSA and the proximal descendingthoracic aneurysm. The postoperative recovery wasuneventful. The follow-up thoracic CTA revealed noendoleak, no graft migration, and complete exclusion

* Correspondence: kimtcs@naver.com; tcskimgh@gmail.com1Department of Thoracic and cardiovascular surgery, Chonbuk NationalUniversity Medical School, Chonbuk National University Hospital, 20Geonji-Ro, Geumam-dong, Deokjin-gu, Jeonju 54907, Republic of KoreaFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Kim and Kim Journal of Cardiothoracic Surgery (2018) 13:130 https://doi.org/10.1186/s13019-018-0817-3

of the ARSA and aneurysm. The right carotid to sub-clavian artery re-routing was showed to be excellentstructural integrity and normal flow patterns withwell-preserved right vertebral artery and right upperlimb flow (Fig. 2). He was asymptomatic withcomplete resolution of his cough and dysphagia.

Discussion and conclusionAn ARSA is the most common congenital abnormalityof the aortic arch [2]. An ARSA does not usually causesymptoms and can be discovered incidentally duringlife, or may be an incidental finding at autopsy [1, 2].Thoracic aneurysm combined with an ARSA requirethe specific therapy because both atherosclerosis withprogressive aortic elongation and aneurysm formationof the ARSA. Also, the isolated ARSA can result indysphagia or dyspnea due to compression of theesophagus or the trachea and with this, aneurysmalformation at this location can cause serious complica-tions, such as rupture, dissection, compression of

neighboring structures, and distal embolization.Treatment is recommended if the patient is symp-tomatic, has a Kommerell diverticulum > 3 cm indiameter, a symptomatic descending aortic aneurysm,or aneurysmal rupture [1, 3]. In our patient, thelarge-fusiform proximal descending aortic aneurysmlocated at Zone 3 and a symptomatic ARSA causingdysphagia convinced us to performed repair.Conventional open repair for ARSA combined thor-

acic aneurysm is still associated with high mortalityand morbidity, as well as neurological events [1, 2].Therefore, nowadays, in order to provide a lessinvasive treatment, a hybrid approach consisting ofsubclavian-to-carotid transposition or bypass andTEVAR employing straight stent-graft is still advisable.We planned single-stage hybrid procedure. First, weperformed right common carotid-to-right subclavianartery transposition along with ARSA proximalligation. One hour later, we performed TEVAR. DuringTEVAR for combined aortic aneurysm, the patients

Fig. 1 a-b Computed tomographic angiography showed a fusiform proximal descending aortic aneurysm (asterisk) distal to an ARSA(white arrow) with compressed esophagus (black arrow). c In operative field, ARSA (asterisk) to right carotid artery transposition (whitearrow) with a ligation of the ARSA distal to the right vertebral (arrow head) and mammary arteries

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with coverage of the ASA without revascularizationare at a higher risk of neurological complications suchas posterior stroke and ischemic spinal cord damagethan patients with revascularization [3, 4, 5]. We thinkthat the right carotid to subclavian artery re-routingrevascularization is a better strategy than bypass sur-gery using the artificial graft in order to preservecirculation of posterior brain, spinal cord, internalmammary artery and upper limb and to prevent largeretrograde type II endoleaks, as well as simplicity anddurability. We confirmed the preservation of the rightvertebral artery and right upper limb flow in follow-upCTA and no postoperative neurologic complicationfor 2 years.

AbbreviationsARSA: Aberrant right subclavian artery; CTA: Computed tomographicangiography scan; TEVAR: Thoracic endovascular aortic repair

AcknowledgementsNot applicable.

FundingFunding from Research Institute of Clinical Medicine of Chonbuk NationalUniversity and Biomedical Research Institute of Chonbuk National UniversityHospital is gratefully acknowledged.

Availability of data and materialsData Availability Guidance for Authors and Editors.

Authors’ contributionsKHK is the corresponding author. KHK conceived of the study andparticipated in its design and coordination. TYK and KHK helped to draftthe manuscript. Both authors read and approved the final manuscript.

Ethics approval and consent to participateNot applicable.

Consent for publicationConsent for publication of this case report in its entirety was obtained fromthe patient.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Department of Thoracic and cardiovascular surgery, Chonbuk NationalUniversity Medical School, Chonbuk National University Hospital, 20Geonji-Ro, Geumam-dong, Deokjin-gu, Jeonju 54907, Republic of Korea.2Research Institute of Clinical Medicine of Chonbuk National University andBiomedical Research Institute of Chonbuk National University Hospital, 20Geonji-Ro, Geumam-dong, Deokjin-gu, Jeonju 54907, Republic of Korea.

Received: 19 October 2018 Accepted: 3 December 2018

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Fig. 2 Computed tomographic angiography showing the result of hybrid treatment with transposition of right subclavian artery in theright common carotid artery (arrow) with intact right vertebral artery vertebral (arrow head) and thoracic endovascular aneurysm repairwith complete occlusion of ARSA

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