Case reports
Symptomatic Atherosclerotic Stenotic Disease of an Aberrant Right Subclavian Artery Christopher F. Roland, MD, Kenneth J. Cherry, Jr., MD, Rochester, Minnesota
Symptomatic atherosclerotic stenosis of an aberrant subclavian artery is exceedingly rare. Herein we describe a patient with this diagnosis who presented with arm claudication, and was treated with carotid-subclavian bypass. (Ann Vasc Surg 1991 ;5:196-198). KEY WORDS: pass.
Aberrant subclavian artery; atherosclerosis; carotid-subclavian by-
Hunauld [1] first described the anatomy of the aberrant right subclavian artery in 1735. While most c o m m o n l y asymptomatic, surgical intervention in patients with dysphagia due to the typical retroesophageal course of the aberrant artery [2] or with aneurysmal dilatation of the anomalous vessel [3] has been well described. Symptomatic, atherosclerotic, stenotic disease of the aberrant artery is exceedingly rare, and operative treatment of this entity has not previously been described to our knowledge. Herein we report a case of atherosclerotic stenosis of an aberrant right subclavian artery, which presented with severe arm claudication, and was treated with carotid-subclavian bypass.
CASE REPORT A 65-year-old housewife presented with a three-month history of increasing right arm claudication. She com-
From the Section of Vascular Surgery, Mayo Clinic and Mayo Foundation Rochester, Minnesota. Reprint requests: Kenneth J. Cherry, Jr., MD, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.
plained of exertional arm pain, particularly in the medial aspect of the upper arm, which was relieved with rest. She also stated that her right hand felt cooler than herleft. She denied any history of trauma to the chest or arm. She had no history of a sudden onset of ischemic symptoms, nor of discoloration consistent with atheroembolic disease. She had been treated with pentoxifylline, without improvement. Her past history was negative for symptoms of cerebrovascular or cardiovascular disease, hypertension, or diabetes. She denied symptoms of collagen vascular disease. She had smoked cigarettes for many years. On physical examination she had no palpable pulses over the right subclavian, axillary, radial or ulnar arteries. Left upper extremity pulses were normal, as were her carotid and temporal pulses. There was elevation pallor of the right arm. Doppler pressure in the right brachial artery was 80 mmHg, whereas in the left brachial artery pressure was 160 mmHg. Aortic arch and subclavian arteriography revealed an aberrant right subclavian artery, originating distal to the left subclavian artery (Fig. 1). There were marked atherosclerotic changes involving the right subclavian, with a 90% stenosis just proximal to the origin of the right vertebral artery (Fig. 2). Vertebral flow was retrograde, and subsequently perfused the subclavian artery distal to the stenosis. There were nonstenotic atherosclerotic changes at both carotid bifurcations and in the proximal left subclavian artery. Subsequent computed tomo196
VOLUME 5 NO 2 - 1991
ATHEROSCLEROT1C STENOTIC A B E R R A N T RSA
Fig. 1. Aberrant right subclavian artery (arrow), originating distal to left subclavian artery.
graphic (CT) scan of the mediastinum delineated the retroesophageal course of the aberrant artery, revealing no evidence of aneurysmal dilatation. Circulation to the right arm was restored by a right carotid-to-subclavian bypass. A 7 mm knitted Dacron graft was sewn end-to-side to the common carotid artery, and end-to-end to the right subclavian artery, which had been divided just distal to the internal mammary artery. There was a strong right radial pulse, and flow in the graft measured 250 cc per minute. Postoperatively the patient made an uneventful recovery and was discharged with equal blood pressures in her upper extremities. She was symptom-free 12 months after surgery, with normal right upper extremity pulses and equal blood pressure in both upper extremities.
DISCUSSION Aberrant origin of the right subclavian artery has been reported to occur at an incidence between 0.4
197
and 2.0% [4]. The first description of clinical symptoms related to this abnormal vessel is B a y f o r d ' s [5] classic case of " d y s p h a g i a lusoria," published in 1794. Surgical treatment, in the form of division of the aberrant artery, was initially described by Gross [6] in 1946. Aneurysmal dilatation of an aberrant right subclavian artery was first reported by McCallen and Schaff [7] in 1956. Jebara and associates [8] recently compiled a series of 33 patients with this condition from the literature. Although the etiology of the vast majority of these a n e u r y s m s was atherosclerosis, no patient had s y m p t o m a t i c arm ischemia. Patients with aortic dissection in association with aberrant subclavian arteries have also been described [9], although it is not clear if the anomaly was a causative factor. Occlusive disease of aberrant subclavian arteries appears to be very rare. Felson [4] describes a single a s y m p t o m a t i c patient with a reduced pulse in the right arm. Rowe [10] describes two patients with aberrant right subclavian arteries and retrograde flow in the right vertebral artery ( " s u b c l a v i a n steal"). One of these patients gave a one-year history of right arm claudication, while the other was asymptomatic. Mulligan I l l ] briefly mentions two patients with stenosis of aberrant right subclavian arteries who underwent " s u c c e s s f u l r e p a i r , " but no details of the degree of stenosis or preoperative s y m p t o m s are provided. Mulligan [11] speculates that the abnormal angle of origin of the aberrant artery, with resultant turbulence and increased shearing forces, predisposes the artery to atherosclerosis. H o w e v e r , the paucity of reports of symptomatic occlusive disease involving these aberrant arteries, despite the relatively high incidence of this malformation and widespread atherosclerotic disease in the population, make such a predisposition unlikely. Treatment of the stenotic aberrant subclavian artery should be similar to the treatment of symptomatic occlusive disease in the non-aberrant artery; either transposition of the artery to the common carotid, or carotid-subclavian bypass [12]. Prior to surgery, concomitant aneurysmal disease of the artery should be excluded by CT scanning of the mediastinum.
REFERENCES 1. HUNAULD PM. Examen de quelques parties d'un singe. Hist Acad Roy Sci 17352:516-523. {:
:
Fig. 2. High grade atheroselerotic stenosis of aberrant right subclavian artery (arrow).
2. SABISTON DC JR, SPENCE FE. Surgery of the chest. Philadelphia, PA, W.B. Saunders, 1990, pp 1153-1154. 3. AUSTIN EH, WOLFE WG. Aneurysm of aberrant subclavian artery with a review of the literature. J Vasc Sure 1985;2:571-577. 4. FELSON B, COHEN S, COURTER S, et al. Anomalous right subclavian artery. Radiology 1950;54:340-348.
198
ATHEROSCLEROT1C STENOTIC ABERRANT RSA
5. BAYFORD D. An account of a singular case of obstructed deglutition. Memoirs Med Soc London 1794;Ed 2, 2:275-286. 6. GROSS RE. Surgical treatment for dysphagia lusoria. Ann Surg 1946;124:532-534. 7. MCCALLEN AM, SCHAFF B. Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-563. 8. JEBARA VA, ARNAUD-CROZAT E, ANGEL F, et al. Aberrant right subclavian artery aneurysm: report of a case and review of the literature. Ann Vasc Surg 1989;3:68-73. 9. WEINBERGER G, RANDALL PA, PARKER FB, et al. Involvement of an aberrant right subclavian artery in dissec-
HI"
ANNALS OF VASCULARSURGERY
tion of the thoracic aorta: diagnostic and therapeutic implications. Am J Roentgenol 1977;129:653~55. 10. ROWE DM, BECKER GJ, SCOTT JA, et al. Right subclavian steal associated with aberrant right subclavian artery. AJNR 1988;9:604-606. 11. MULLIGAN S, NATH PH, KELLER FS, et al. Acquired disease of aberrant subclavian arteries. J Thorac lmag 1989;4:76-81. 12. EDWARDS NH, MULHERIN SL. The surgical reconstruction of the proximal subclavian and vertebral artery, J Vasc Surg 1985;2:634-642.
m
Symptomatic Atherosclerotic Stenotic Disease of an Aberrant Right Subclavian Artery Christopher F. Roland, MD, Kenneth J. Cherry, Jr., MD, Rochester, Minnesota
Symptomatic atherosclerotic stenosis of an aberrant subclavian artery is exceedingly rare. Herein we describe a patient with this diagnosis who presented with arm claudication, and was treated with carotid-subclavian bypass. (Ann Vasc Surg 1991 ;5:196-198). KEY WORDS: pass.
Aberrant subclavian artery; atherosclerosis; carotid-subclavian by-
Hunauld [1] first described the anatomy of the aberrant right subclavian artery in 1735. While most c o m m o n l y asymptomatic, surgical intervention in patients with dysphagia due to the typical retroesophageal course of the aberrant artery [2] or with aneurysmal dilatation of the anomalous vessel [3] has been well described. Symptomatic, atherosclerotic, stenotic disease of the aberrant artery is exceedingly rare, and operative treatment of this entity has not previously been described to our knowledge. Herein we report a case of atherosclerotic stenosis of an aberrant right subclavian artery, which presented with severe arm claudication, and was treated with carotid-subclavian bypass.
CASE REPORT A 65-year-old housewife presented with a three-month history of increasing right arm claudication. She com-
From the Section of Vascular Surgery, Mayo Clinic and Mayo Foundation Rochester, Minnesota. Reprint requests: Kenneth J. Cherry, Jr., MD, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905.
plained of exertional arm pain, particularly in the medial aspect of the upper arm, which was relieved with rest. She also stated that her right hand felt cooler than herleft. She denied any history of trauma to the chest or arm. She had no history of a sudden onset of ischemic symptoms, nor of discoloration consistent with atheroembolic disease. She had been treated with pentoxifylline, without improvement. Her past history was negative for symptoms of cerebrovascular or cardiovascular disease, hypertension, or diabetes. She denied symptoms of collagen vascular disease. She had smoked cigarettes for many years. On physical examination she had no palpable pulses over the right subclavian, axillary, radial or ulnar arteries. Left upper extremity pulses were normal, as were her carotid and temporal pulses. There was elevation pallor of the right arm. Doppler pressure in the right brachial artery was 80 mmHg, whereas in the left brachial artery pressure was 160 mmHg. Aortic arch and subclavian arteriography revealed an aberrant right subclavian artery, originating distal to the left subclavian artery (Fig. 1). There were marked atherosclerotic changes involving the right subclavian, with a 90% stenosis just proximal to the origin of the right vertebral artery (Fig. 2). Vertebral flow was retrograde, and subsequently perfused the subclavian artery distal to the stenosis. There were nonstenotic atherosclerotic changes at both carotid bifurcations and in the proximal left subclavian artery. Subsequent computed tomo196
VOLUME 5 NO 2 - 1991
ATHEROSCLEROT1C STENOTIC A B E R R A N T RSA
Fig. 1. Aberrant right subclavian artery (arrow), originating distal to left subclavian artery.
graphic (CT) scan of the mediastinum delineated the retroesophageal course of the aberrant artery, revealing no evidence of aneurysmal dilatation. Circulation to the right arm was restored by a right carotid-to-subclavian bypass. A 7 mm knitted Dacron graft was sewn end-to-side to the common carotid artery, and end-to-end to the right subclavian artery, which had been divided just distal to the internal mammary artery. There was a strong right radial pulse, and flow in the graft measured 250 cc per minute. Postoperatively the patient made an uneventful recovery and was discharged with equal blood pressures in her upper extremities. She was symptom-free 12 months after surgery, with normal right upper extremity pulses and equal blood pressure in both upper extremities.
DISCUSSION Aberrant origin of the right subclavian artery has been reported to occur at an incidence between 0.4
197
and 2.0% [4]. The first description of clinical symptoms related to this abnormal vessel is B a y f o r d ' s [5] classic case of " d y s p h a g i a lusoria," published in 1794. Surgical treatment, in the form of division of the aberrant artery, was initially described by Gross [6] in 1946. Aneurysmal dilatation of an aberrant right subclavian artery was first reported by McCallen and Schaff [7] in 1956. Jebara and associates [8] recently compiled a series of 33 patients with this condition from the literature. Although the etiology of the vast majority of these a n e u r y s m s was atherosclerosis, no patient had s y m p t o m a t i c arm ischemia. Patients with aortic dissection in association with aberrant subclavian arteries have also been described [9], although it is not clear if the anomaly was a causative factor. Occlusive disease of aberrant subclavian arteries appears to be very rare. Felson [4] describes a single a s y m p t o m a t i c patient with a reduced pulse in the right arm. Rowe [10] describes two patients with aberrant right subclavian arteries and retrograde flow in the right vertebral artery ( " s u b c l a v i a n steal"). One of these patients gave a one-year history of right arm claudication, while the other was asymptomatic. Mulligan I l l ] briefly mentions two patients with stenosis of aberrant right subclavian arteries who underwent " s u c c e s s f u l r e p a i r , " but no details of the degree of stenosis or preoperative s y m p t o m s are provided. Mulligan [11] speculates that the abnormal angle of origin of the aberrant artery, with resultant turbulence and increased shearing forces, predisposes the artery to atherosclerosis. H o w e v e r , the paucity of reports of symptomatic occlusive disease involving these aberrant arteries, despite the relatively high incidence of this malformation and widespread atherosclerotic disease in the population, make such a predisposition unlikely. Treatment of the stenotic aberrant subclavian artery should be similar to the treatment of symptomatic occlusive disease in the non-aberrant artery; either transposition of the artery to the common carotid, or carotid-subclavian bypass [12]. Prior to surgery, concomitant aneurysmal disease of the artery should be excluded by CT scanning of the mediastinum.
REFERENCES 1. HUNAULD PM. Examen de quelques parties d'un singe. Hist Acad Roy Sci 17352:516-523. {:
:
Fig. 2. High grade atheroselerotic stenosis of aberrant right subclavian artery (arrow).
2. SABISTON DC JR, SPENCE FE. Surgery of the chest. Philadelphia, PA, W.B. Saunders, 1990, pp 1153-1154. 3. AUSTIN EH, WOLFE WG. Aneurysm of aberrant subclavian artery with a review of the literature. J Vasc Sure 1985;2:571-577. 4. FELSON B, COHEN S, COURTER S, et al. Anomalous right subclavian artery. Radiology 1950;54:340-348.
198
ATHEROSCLEROT1C STENOTIC ABERRANT RSA
5. BAYFORD D. An account of a singular case of obstructed deglutition. Memoirs Med Soc London 1794;Ed 2, 2:275-286. 6. GROSS RE. Surgical treatment for dysphagia lusoria. Ann Surg 1946;124:532-534. 7. MCCALLEN AM, SCHAFF B. Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-563. 8. JEBARA VA, ARNAUD-CROZAT E, ANGEL F, et al. Aberrant right subclavian artery aneurysm: report of a case and review of the literature. Ann Vasc Surg 1989;3:68-73. 9. WEINBERGER G, RANDALL PA, PARKER FB, et al. Involvement of an aberrant right subclavian artery in dissec-
HI"
ANNALS OF VASCULARSURGERY
tion of the thoracic aorta: diagnostic and therapeutic implications. Am J Roentgenol 1977;129:653~55. 10. ROWE DM, BECKER GJ, SCOTT JA, et al. Right subclavian steal associated with aberrant right subclavian artery. AJNR 1988;9:604-606. 11. MULLIGAN S, NATH PH, KELLER FS, et al. Acquired disease of aberrant subclavian arteries. J Thorac lmag 1989;4:76-81. 12. EDWARDS NH, MULHERIN SL. The surgical reconstruction of the proximal subclavian and vertebral artery, J Vasc Surg 1985;2:634-642.
m
