Abstract
Aberrant right subclavian artery (ARSA) is a congenital anomaly of the aortic arch. Aneurysm of the origin of the artery (Kommerell’s diverticulum) and its roundabout route behind the esophagus or trachea can cause serious complications including compression of surrounding structures, coexisting aneurysm and dissection of adjacent aorta, and dilatation and rupture of ARSA itself. A number of surgical strategies have been proposed for treatment of this anomaly. A 68-year-old woman was referred to our hospital. Computed tomography (CT) revealed ARSA and aortic dissection (DeBakey IIIb) with 68 mm aortic aneurysm, which needed graft replacement ranging from aortic arch to the end of descending aorta. Two-stage operation, total arch replacement with ARSA reconstruction and descending aorta replacement were performed. In the first surgery, 8 mm Gelweave graft was anastomosed to the side of right axillar artery immediately prior to median sternotomy. Using hypothermic circulatory arrest and antegrade cerebral perfusion, ARSA ostium was closed by pledgeted sutures inside the aorta. Finally, 8 mm graft was pulled into anterior mediastinum, and anastomosed to the first branch of quadrifurcated aortic graft. Postoperative CT showed successful repairs of all aortic branches, especially the distal portion of ARSA, closed at ostium, was thrombosed just proximal to the origin of right vertebral artery. ARSA and coexisting thoracic aortic aneurysm (or dissection) can be repaired safely with total arch replacement via median sternotomy and ARSA reconstruction through anterior mediastinal route with its ostium closure.
