Hybrid Treatment of the Aberrant Right Subclavian Artery (Arteria Lusoria): Feasibility Study on 180 Angio-CTs

Abstract

Background: The aberrant right subclavian artery or arteria lusoria (AL) is the most frequent anatomical variation of the supra-aortic trunks (SAT). Treatment is only warranted in the presence of an aneurysm because of the risk of rupture, or in symptomatic cases with signs of compression of the esophagus or the trachea, with embolisms causing right upper limb ischemia of vertebrobasilar cerebrovascular accidents. The conventional surgical treatment of AL is the closure of the origin of AL and the revascularization of the right subclavian artery through a left thoracotomy. With the appearance of endovascular techniques, some of these patients can be treated with minimally invasive hybrid techniques. The aim of this study is to evaluate the feasibility of the endovascular treatment of AL based on the radioanatomical analysis of the thoracic angio-computed tomographies.

Methods: We analyzed 180 thoracic angio-computed tomographies using millimeter cuts (<1.2 mm) performed between 2010 and 2015 in the Nancy University Hospital in which an AL was fortuitously discovered. Symptomatic ALs and pediatric patients were excluded. The diameters of the SATs and the aorta and the distances between the SATs were measured. The data were processed with the t-test using the SPSS 22 software.

Results: Our results showed the presence of a Kommerell diverticulum in 36 cases (20%) and of a bi-carotid trunk in 91 cases (50.5%). The average distance between the left subclavian artery (LSCA) and AL was 5.4 ± 4.3 mm. To obtain a proximal neck >20 mm for the implantation of a thoracic stent graft, a double transposition or bypass was always necessary (LSCA to left common carotid artery, AL to right common carotid). An additional debranching of the left common carotid artery was necessary in 33.8% of the cases and of all the SATs in 2.9% of the cases.

Conclusions: The radio-anatomical study showed that no patient was eligible for conventional thoracic endovascular aneurysm repair to treat an aneurysmal AL. The hybrid approach is feasible using a double transposition or a bypass before the implantation of a stent graft, if needed associated with a debranching of the common carotid arteries.