Aberrant Right Subclavian Artery Case Study

Aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly. The estimated incidence is 0.5-2%. They are often asymptomatic, but approximately 10% of people may complain of dysphagia lusoria4 or other compressive symptoms. In ARSA of the Innominate artery, the right subclavian artery arises as its own branch from the aortic arch distal to the origin of the left subclavian artery. Its relationship to the esophagus is variable with 80% posterior to esophagus, 15% between the esophagus and trachea, and 5% anterior to the trachea. There have been very few reports of acute dissection of the aberrant right subclavian artery. We present a new management strategy for symptomatic iatrogenic aberrant right subclavian artery dissection.

Physical exam was remarkable for a diminished right radial pulse as well as decreased sensation and motor activity in the right hand. Anticoagulation was started and CTA of the neck and chest was performed. This showed a dissected aberrant right subclavian artery arising as the last major branch of a bovine aortic arch. The dissection was found to extend to the right axillary artery. The right vertebral artery arose from the false lumen. The left vertebral artery had high grade stenosis at its origin. The carotid arteries had no hemodynamically significant stenosis (figure

Through a neck incision the right carotid, right subclavian and right vertebral arteries were exposed. The right brachial artery was exposed through a right upper arm incision. Right vertebral artery was transposed to the right common carotid artery. Right common carotid to right brachial artery bypass using 6mm PTFE graft was carried out. A Zenith TX2 thoracic aortic endovascular graft (COOK Medical, Indiana, USA) was then placed using right femoral approach to cover and occlude the origin of the aberrant right subclavian artery. A 7-french sheath was placed through surgically exposed right brachial artery, and an AMPLATZER Vascular Plug II (ST. JUDE MEDICALTM, Minnesota, USA) was placed in the aberrant right subclavian artery close to its origin. Completion angiogram showed no flow through the native right subclavian artery with complete patency of right carotid, right brachial and vertebral arteries (figure 3). The patient had an uneventful recovery with resolution of right arm symptoms and was discharged. At six months post procedure patient continues to be asymptomatic and all vessels except the aberrant right subclavian are