Mediastinoscopy-assisted Treatment of an Aberrant Right Subclavian Artery

Abstract

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by the origin of the right subclavian artery from the aortic arch distally to the left subclavian artery. We describe the case of a young patient with symptomatic ARSA treated by mediastinoscopyassisted ligation at its origin and subclavianecarotid transposition.The aberrant right subclavian artery (ARSA) is a rare congenital anomaly characterized by a retroesophageal course of the right subclavian artery, whose origin from the aortic arch is distal to the left subclavian artery. The majority of patients with ARSA are asymptomatic; however, this anomaly may cause a condition named dysphagia lusoria. CASE REPORTA 36-year-old woman was referred to our center for a history of progressively worsening dysphagia and severe loss of weight. The patient reported an initial dysphagia for solids which had started 2 months prior. This has recently progressed to a dysphagia for liquids as well. Both neurological and otolaryngology evaluations were negative for organic or functional swallowing impairments. Due to her malnourished conditions, parental nutrition was administered. Videofluoroscopy was then performed and demonstrated an external compression during bolus progression in the proximal zone of esophagus on the anterolateral left side of the esophagus. This finding was considered highly suggestive for an ARSA. A computed tomography angiography (CTA) confirmed the diagnosis of an 8-mm ARSA and also revealed the associated anomalous origin of the left common carotid artery from the innominate trunk (Fig. 1). Due to the significant symptoms, surgical intervention was then planned. Under general anesthesia, the patient was placed in the supine position. A sandbag was positioned in the midline behind her shoulders to achieve a better extension of the neck. Through a 6 cm right supraclavicular incision, we sectioned the clavicular head of the sternocleidomastoid muscle and the anterior scalene muscle, after identification of the phrenic nerve. This helped to expose the ARSA, the mammary artery, the thyreocervical trunk, and the right vertebral artery. Then, with the use of a mediastinoscope, we followed the proximal aberrant subclavian artery in the retroesophageal space until 1 cm from its origin off the aortic arch. After systemic heparinization, a curved Satinsky vascular clamp was placed at the origin of ARSA (Fig. 2A); then, we oversewed the proximal portion of this artery as close to its origin as possible with a 2 Mersilene suture and transected it. The distal portion of the right subclavian artery was trimmed and with a careful preservation of the right vertebral artery, an end-to-side anastomosis was made with the right common carotid artery with a polypropylene 6-0 (Fig. 2B). No intraoperative complications occurred. Her postoperative course was uneventful and she tolerated regular diet with immediate regression of her dysphagia. On second postoperative day, a Gastrografin transit confirmed the absence of any obstruction in the esoph...

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