E Kieffer1, A Bahnini, F Koskas. 1. Department of Vascular Surgery, Pitié-Salpêtrière University Hospital, Paris, France.
Abstract
PURPOSE: Because of the scarcity of large series in the literature, our experience with surgery for aberrant subclavian arteries (aSA) in adults was reviewed. METHODS: During the last 16 years we have surgically treated 33 adult patients with aSA. Twenty-eight patients had a left-sided aortic arch with a right aSA whereas five had a right-sided aortic arch with a left aSA. Eleven patients (group 1) had dysphagia caused by esophageal compression by a nonaneurysmal aSA; five patients (group 2) had ischemic symptoms caused by occlusive disease of a nonaneurysmal aSA; 10 patients (group 3) had aneurysms of the aSA with or without symptoms caused by esophageal compression or arterial thromboembolism; and seven patients (group 4) had an aSA arising from a diseased (usually aneurysmal) thoracic aorta. In all cases the divided aSA was revascularized, most often by direct transposition into the ipsilateral common carotid artery. Nine of the 16 patients in groups 1 and 2 underwent operation with a cervical approach alone. In the remaining seven, the cervical approach was combined with a median sternotomy (six cases) or a left thoracotomy (one case). In the 17 patients in groups 3 and 4, either a cervical approach (two cases), a median sternotomy (four cases), or a two-staged approach combining a supraclavicular incision on the side of the aSA with a posterolateral thoracotomy on the side of the aortic arch (11 cases) was used. Aortic cross-clamping was required in 12 of these patients to perform the transaortic closure of the origin of the aSA with patch angioplasty (three cases), or prosthetic replacement of the descending thoracic aorta (nine cases). Cardiopulmonary bypass was used in six patients (including three with hypothermic circulatory arrest). RESULTS: Four patients, all in groups 3 and 4, died after operation: two of multiorgan failure, one of heart failure, and one of esophageal rupture. Satisfactory clinical and anatomic results were obtained in the remaining 29 patients. CONCLUSIONS: The surgical approach to aSA must be flexible and adapted to the anatomic conditions found. We recommend routine reconstruction of the aSA to avoid ischemic complications in the vertebrobasilar territory or upper extremity. Provision should be made for cardiopulmonary bypass in patients with aneurysm of aSA or associated aortic aneurysm.
PURPOSE: Because of the scarcity of large series in the literature, our experience with surgery for aberrant subclavian arteries (aSA) in adults was reviewed. METHODS: During the last 16 years we have surgically treated 33 adult patients with aSA. Twenty-eight patients had a left-sided aortic arch with a right aSA whereas five had a right-sided aortic arch with a left aSA. Eleven patients (group 1) had dysphagia caused by esophageal compression by a nonaneurysmal aSA; five patients (group 2) had ischemic symptoms caused by occlusive disease of a nonaneurysmal aSA; 10 patients (group 3) had aneurysms of the aSA with or without symptoms caused by esophageal compression or arterial thromboembolism; and seven patients (group 4) had an aSA arising from a diseased (usually aneurysmal) thoracic aorta. In all cases the divided aSA was revascularized, most often by direct transposition into the ipsilateral common carotid artery. Nine of the 16 patients in groups 1 and 2 underwent operation with a cervical approach alone. In the remaining seven, the cervical approach was combined with a median sternotomy (six cases) or a left thoracotomy (one case). In the 17 patients in groups 3 and 4, either a cervical approach (two cases), a median sternotomy (four cases), or a two-staged approach combining a supraclavicular incision on the side of the aSA with a posterolateral thoracotomy on the side of the aortic arch (11 cases) was used. Aortic cross-clamping was required in 12 of these patients to perform the transaortic closure of the origin of the aSA with patch angioplasty (three cases), or prosthetic replacement of the descending thoracic aorta (nine cases). Cardiopulmonary bypass was used in six patients (including three with hypothermic circulatory arrest). RESULTS: Four patients, all in groups 3 and 4, died after operation: two of multiorgan failure, one of heart failure, and one of esophageal rupture. Satisfactory clinical and anatomic results were obtained in the remaining 29 patients. CONCLUSIONS: The surgical approach to aSA must be flexible and adapted to the anatomic conditions found. We recommend routine reconstruction of the aSA to avoid ischemic complications in the vertebrobasilar territory or upper extremity. Provision should be made for cardiopulmonary bypass in patients with aneurysm of aSA or associated aortic aneurysm.
Authors: Arjan P Schouten van der Velden; Paul Berger; Attila G Krasznai; Peter van Duijvendijk; J Adam van der Vliet Journal: J Gastrointest Surg Date: 2009-06-26 Impact factor: 3.452