© 2013 Wiley Periodicals, Inc.
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Single-Stage Frozen Elephant Trunk Reconstruction in Complex Disease of the Aortic Arch with Aberrant Right Subclavian Artery Alessandro Leone, M.D., Antonio Pantaleo, M.D., Davide Pacini, M.D., Luca Di Marco, M.D., and Roberto Di Bartolomeo, M.D. Department of Cardiac Surgery, Sant’Orsola-Malpighi Hospital, Bologna, Italy ABSTRACT Aberrant right subclavian artery (ARSA) is the most common anomaly of the aortic arch. We describe two cases of patients affected by complex lesions of the aortic arch with the ARSA, both treated with the frozen elephant trunk technique and reconstruction of the ARSA. doi: 10.1111/jocs.12257 (J Card Surg
2014;29:234–237) Aberrant right subclavian artery (ARSA), also called arteria lusoria, is the most common anomaly of the aortic arch, with an incidence ranging between 0.4% and 2%.1 Occasionally, it may cause dyspnea, stridor, dysphagia, and chest pain and serious complications such as distal embolization, rupture, and compression of neighboring structures. Moreover, it may be associated with other congenital anomalies, including the truncus bicaroticus (a common origin of both common carotid arteries).2 We describe two cases of complex lesions of the aortic arch with the ARSA, treated with the frozen elephant trunk (FET) technique. PATIENT PROFILES Patient 1 A 73-year-old male was referred for evaluation of a 4.5-cm ascending aortic aneurysm without any valve disease. The angioCT scan showed a distal aortic arch aneurysm with the presence of an ARSA associated with truncus bicaroticus (Fig. 1). Preoperative coronary angiography showed a severe stenosis (70%) of the left anterior descending coronary artery (LAD). The operation was performed through a full sternotomy. After systemic heparinization, the right femoral
artery and right atrium were cannulated for cardiopulmonary bypass. Truncus bicarotidus was anastomosed with an 8-mm tubular dacron prosthesis (Vascutek1, Inchinnan, Scotland, UK) (termino-lateral anastomosis) and the ARSA was anastomosed with another 8-mm tubular dacron prosthesis (termino-terminal anastomosis) for the antegrade selective cerebral perfusion (ASCP) in order to perfuse the right vertebral artery. Systemic cooling was then initiated and the ascending aorta was clamped. Afterwards, a distal anastomosis to the LAD was performed with a saphenous vein graft. ASCP was achieved through the two tubular dacron prostheses and the ARSA proximal end was ligated and oversewn. The FET technique with the E-vita open prosthesis (Jotec, Inc., Hechingen, Germany) was used for the aortic arch replacement. The stent-graft system was introduced in an antegrade manner in the descending aorta and the distal anastomosis was performed proximal to the left subclavian artery origin, previously prepared using a Teflon felt externally and fixed with some pledgetted stitches. The arch vessels were then reimplanted using the ‘‘en-bloc technique’’ (truncus bicarotidus and left subclavian artery) while the ARSA was separately reimplanted with the tubular dacron prosthesis. The postoperative course was uneventful and the predischarge angioCT scan showed a patent reconstruction of the aortic arch and the ARSA (Fig. 2).
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Alessandro Leone, M.D., Department of Cardiac Surgery, S’Orsola-Malpighi Hospital, Via Massarenti 9, 40125 Bologna, Italy. Fax: þ39051345990; e-mail: leone.alessandro@yahoo. it
Patient 2 A 45-year-old male was symptomatic with back pain and a diagnosis of chronic type B dissection. The
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Figure 1. First case, preoperative angioCT scan, aortic arch aneurysm; the arrow shows the aberrant right subclavian artery.
angioCT scan showed also an ARSA (3.2 cm) originating proximally to the isthmus (Fig. 3). The intimal flap involved the posterior part of the aortic arch. The presence of an acute aortic angle and the absence of a proximal landing zone excluded the use of an endograft. A preoperative transthoracic echocardiogram showed normal left ventricular function with no valvular disease. Preoperative coronary angiography showed no coronary lesions. This case was performed through a full sternotomy with a right infraclavicular and right femoral incision. The right femoral artery was exposed and a Y on the artery line was prepared for the reperfusion; subsequently a guidewire was introduced through the femoral artery in order to identify the true lumen for the FET. The aortic arch, the supra-aortic vessels, and the ARSA were exposed. The cardiopulmonary bypass was instituted through the ascending aorta and the right atrium. Systemic cooling was initiated and the ARSA was ligated on the aortic isthmus. After the ascending aorta was clamped and cardioplegia infused, at 25 8C of nasopharyngeal temperature the clamp was removed and two cannulae were inserted in the right and left
Figure 2. First case, postoperative reconstruction.
common carotid artery for the ASCP with the left subclavian artery clamped, in order to avoid the steal phenomenon. The distal anastomosis was prepared using teflon felt externally and fixed with the usual four pledgetted stitches to reapproximate the true and false lumen. The stent-graft system (E-vita open; Jotec, Inc.) was introduced in an antegrade manner in the descending aorta over the previously positioned stiff guidewire. Supra-aortic vessels were reimplanted using the enbloc technique and the circulation restored by the right femoral artery previously prepared using a Y on the artery line inflow. The ARSA was then reimplanted separately with the 8-mm tubular dacron prosthesis on the ascending aorta and its distal end oversewn. The postoperative course was characterized by the presence on the transthoracic ecocardiogram of a massive pericardial effusion in the eighth postoperative day that required percutaneous drainage. Predischarge angioCT scan showed a patent reconstruction of the ARSA (Fig. 4). Individual patients were not identified, and the need for patient consent was waived.
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Figure 3. Second case, preoperative angioCT scan, type B dissection that involved the posterior part of the aortic arch; the arrow shows the proximal origin of the aberrant right subclavian artery which is involved by the dissection.
DISCUSSION The ARSA is a common anomaly of the aortic arch that is frequently subject to aneurismal degeneration. It results from regression of the right fourth aortic arch between the carotid and subclavian arteries, rather than distal to the subclavian artery.3 There is not a full consensus about the best surgical approach to the repair of this anomaly. Right and left thoracotomies, cervical incision, median sternotomy, and combinations of these approaches have been used. In the largest published series of treated aberrant RSA, Kieffer et al.4 included 33 cases with different therapeutic strategies. They concluded that the surgical approach to the ARSA must be flexible and adapted to the anatomic conditions found. In recent years, a hybrid repair combining endovascular treatment with conventional surgery, the so-called
Figure 4. Second case, postoperative reconstruction.
FET technique,5 has been described as a single-stage procedure for treatment of complex disease of the aortic arch. In our cases, we preferred the FET through median sternotomy, in order to avoid combined incision or twostage operation. The FET technique with a hybrid stent-graft prosthesis has been developed as a means of treating extensive disease of the thoracic aorta. The results described thus far with this technique are acceptable, particularly in view of the extent of aortic disease and the comorbidities of the patients in whom the technique has been used.6 Cerebral monitoring was always achieved with near infrared spectroscopy. Cerebrospinal fluid drainage is a well-known method of spinal cord protection during endovascular and surgical aortic repair and we usually use this technique for spinal cord injury prevention. In some case, the
J CARD SURG 2014;29:234–237
LEONE, ET AL. SINGLE-STAGE FET RECONSTRUCTION
ARSA origin can be difficult to reach with the full median sternotomy approach; however, with the aid of endovascular part of the prosthesis the ARSA origin can be excluded allowing the vessel to thrombose. The distal part of the aberrant subclavian artery has to be always excluded and ligated, in order to avoid a retrograde perfusion and to reduce tension on the esophagus wall. REFERENCES 1. Duff SB, Hicks GL: Aortic arch dissection with an aberrant right subclavian artery: Surgical treatment. Tex Heart Inst J 1986;13(2):233–235.
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2. Murzi M, Mariani M, Tiwari KK: Aberrant right subclavian artery aneurysm in coexistence with a common carotid trunk. Ann Thorac Surg 2009;88(1):e8. 3. Bull PG, Denck H: Aberrant right subclavian artery. Eur J Vasc Surg 1994;8:757–760. 4. Kieffer E, Bahnini A, Koskas F, et al: Aberrant subclavian artery: Surgical treatment in thirty-three adult patients. J Vasc Surg 1994; 19: 100–111. 5. Karck M, Chavan A, Haverich A, et al: The frozen elephant technique: A new treatment for thoracic aortic aneurysm. J Thorac Cardiovasc 2003;125:1550–1553. 6. Tsagakis K, Pacini D, Di Bartolomeo R, et al: Arch replacement and downstream stent grafting in complex aortic dissection: First results of an international registry. Eur J Cardiothorac Surg 2011;39:87–94.
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Single-Stage Frozen Elephant Trunk Reconstruction in Complex Disease of the Aortic Arch with Aberrant Right Subclavian Artery Alessandro Leone, M.D., Antonio Pantaleo, M.D., Davide Pacini, M.D., Luca Di Marco, M.D., and Roberto Di Bartolomeo, M.D. Department of Cardiac Surgery, Sant’Orsola-Malpighi Hospital, Bologna, Italy ABSTRACT Aberrant right subclavian artery (ARSA) is the most common anomaly of the aortic arch. We describe two cases of patients affected by complex lesions of the aortic arch with the ARSA, both treated with the frozen elephant trunk technique and reconstruction of the ARSA. doi: 10.1111/jocs.12257 (J Card Surg
2014;29:234–237) Aberrant right subclavian artery (ARSA), also called arteria lusoria, is the most common anomaly of the aortic arch, with an incidence ranging between 0.4% and 2%.1 Occasionally, it may cause dyspnea, stridor, dysphagia, and chest pain and serious complications such as distal embolization, rupture, and compression of neighboring structures. Moreover, it may be associated with other congenital anomalies, including the truncus bicaroticus (a common origin of both common carotid arteries).2 We describe two cases of complex lesions of the aortic arch with the ARSA, treated with the frozen elephant trunk (FET) technique. PATIENT PROFILES Patient 1 A 73-year-old male was referred for evaluation of a 4.5-cm ascending aortic aneurysm without any valve disease. The angioCT scan showed a distal aortic arch aneurysm with the presence of an ARSA associated with truncus bicaroticus (Fig. 1). Preoperative coronary angiography showed a severe stenosis (70%) of the left anterior descending coronary artery (LAD). The operation was performed through a full sternotomy. After systemic heparinization, the right femoral
artery and right atrium were cannulated for cardiopulmonary bypass. Truncus bicarotidus was anastomosed with an 8-mm tubular dacron prosthesis (Vascutek1, Inchinnan, Scotland, UK) (termino-lateral anastomosis) and the ARSA was anastomosed with another 8-mm tubular dacron prosthesis (termino-terminal anastomosis) for the antegrade selective cerebral perfusion (ASCP) in order to perfuse the right vertebral artery. Systemic cooling was then initiated and the ascending aorta was clamped. Afterwards, a distal anastomosis to the LAD was performed with a saphenous vein graft. ASCP was achieved through the two tubular dacron prostheses and the ARSA proximal end was ligated and oversewn. The FET technique with the E-vita open prosthesis (Jotec, Inc., Hechingen, Germany) was used for the aortic arch replacement. The stent-graft system was introduced in an antegrade manner in the descending aorta and the distal anastomosis was performed proximal to the left subclavian artery origin, previously prepared using a Teflon felt externally and fixed with some pledgetted stitches. The arch vessels were then reimplanted using the ‘‘en-bloc technique’’ (truncus bicarotidus and left subclavian artery) while the ARSA was separately reimplanted with the tubular dacron prosthesis. The postoperative course was uneventful and the predischarge angioCT scan showed a patent reconstruction of the aortic arch and the ARSA (Fig. 2).
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Alessandro Leone, M.D., Department of Cardiac Surgery, S’Orsola-Malpighi Hospital, Via Massarenti 9, 40125 Bologna, Italy. Fax: þ39051345990; e-mail: leone.alessandro@yahoo. it
Patient 2 A 45-year-old male was symptomatic with back pain and a diagnosis of chronic type B dissection. The
J CARD SURG 2014;29:234–237
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Figure 1. First case, preoperative angioCT scan, aortic arch aneurysm; the arrow shows the aberrant right subclavian artery.
angioCT scan showed also an ARSA (3.2 cm) originating proximally to the isthmus (Fig. 3). The intimal flap involved the posterior part of the aortic arch. The presence of an acute aortic angle and the absence of a proximal landing zone excluded the use of an endograft. A preoperative transthoracic echocardiogram showed normal left ventricular function with no valvular disease. Preoperative coronary angiography showed no coronary lesions. This case was performed through a full sternotomy with a right infraclavicular and right femoral incision. The right femoral artery was exposed and a Y on the artery line was prepared for the reperfusion; subsequently a guidewire was introduced through the femoral artery in order to identify the true lumen for the FET. The aortic arch, the supra-aortic vessels, and the ARSA were exposed. The cardiopulmonary bypass was instituted through the ascending aorta and the right atrium. Systemic cooling was initiated and the ARSA was ligated on the aortic isthmus. After the ascending aorta was clamped and cardioplegia infused, at 25 8C of nasopharyngeal temperature the clamp was removed and two cannulae were inserted in the right and left
Figure 2. First case, postoperative reconstruction.
common carotid artery for the ASCP with the left subclavian artery clamped, in order to avoid the steal phenomenon. The distal anastomosis was prepared using teflon felt externally and fixed with the usual four pledgetted stitches to reapproximate the true and false lumen. The stent-graft system (E-vita open; Jotec, Inc.) was introduced in an antegrade manner in the descending aorta over the previously positioned stiff guidewire. Supra-aortic vessels were reimplanted using the enbloc technique and the circulation restored by the right femoral artery previously prepared using a Y on the artery line inflow. The ARSA was then reimplanted separately with the 8-mm tubular dacron prosthesis on the ascending aorta and its distal end oversewn. The postoperative course was characterized by the presence on the transthoracic ecocardiogram of a massive pericardial effusion in the eighth postoperative day that required percutaneous drainage. Predischarge angioCT scan showed a patent reconstruction of the ARSA (Fig. 4). Individual patients were not identified, and the need for patient consent was waived.
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Figure 3. Second case, preoperative angioCT scan, type B dissection that involved the posterior part of the aortic arch; the arrow shows the proximal origin of the aberrant right subclavian artery which is involved by the dissection.
DISCUSSION The ARSA is a common anomaly of the aortic arch that is frequently subject to aneurismal degeneration. It results from regression of the right fourth aortic arch between the carotid and subclavian arteries, rather than distal to the subclavian artery.3 There is not a full consensus about the best surgical approach to the repair of this anomaly. Right and left thoracotomies, cervical incision, median sternotomy, and combinations of these approaches have been used. In the largest published series of treated aberrant RSA, Kieffer et al.4 included 33 cases with different therapeutic strategies. They concluded that the surgical approach to the ARSA must be flexible and adapted to the anatomic conditions found. In recent years, a hybrid repair combining endovascular treatment with conventional surgery, the so-called
Figure 4. Second case, postoperative reconstruction.
FET technique,5 has been described as a single-stage procedure for treatment of complex disease of the aortic arch. In our cases, we preferred the FET through median sternotomy, in order to avoid combined incision or twostage operation. The FET technique with a hybrid stent-graft prosthesis has been developed as a means of treating extensive disease of the thoracic aorta. The results described thus far with this technique are acceptable, particularly in view of the extent of aortic disease and the comorbidities of the patients in whom the technique has been used.6 Cerebral monitoring was always achieved with near infrared spectroscopy. Cerebrospinal fluid drainage is a well-known method of spinal cord protection during endovascular and surgical aortic repair and we usually use this technique for spinal cord injury prevention. In some case, the
J CARD SURG 2014;29:234–237
LEONE, ET AL. SINGLE-STAGE FET RECONSTRUCTION
ARSA origin can be difficult to reach with the full median sternotomy approach; however, with the aid of endovascular part of the prosthesis the ARSA origin can be excluded allowing the vessel to thrombose. The distal part of the aberrant subclavian artery has to be always excluded and ligated, in order to avoid a retrograde perfusion and to reduce tension on the esophagus wall. REFERENCES 1. Duff SB, Hicks GL: Aortic arch dissection with an aberrant right subclavian artery: Surgical treatment. Tex Heart Inst J 1986;13(2):233–235.
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2. Murzi M, Mariani M, Tiwari KK: Aberrant right subclavian artery aneurysm in coexistence with a common carotid trunk. Ann Thorac Surg 2009;88(1):e8. 3. Bull PG, Denck H: Aberrant right subclavian artery. Eur J Vasc Surg 1994;8:757–760. 4. Kieffer E, Bahnini A, Koskas F, et al: Aberrant subclavian artery: Surgical treatment in thirty-three adult patients. J Vasc Surg 1994; 19: 100–111. 5. Karck M, Chavan A, Haverich A, et al: The frozen elephant technique: A new treatment for thoracic aortic aneurysm. J Thorac Cardiovasc 2003;125:1550–1553. 6. Tsagakis K, Pacini D, Di Bartolomeo R, et al: Arch replacement and downstream stent grafting in complex aortic dissection: First results of an international registry. Eur J Cardiothorac Surg 2011;39:87–94.
