How I Do It - Yasui Procedure with Aberrant Right Subclavian Artery Translocation
This video will demonstrate Dr. James Tweddell's surgical strategy in 2-month-old male with diagnosis of aortic atresia, hypoplastic aortic arch, coarctation, large perimembranous VSD, mildly hypoplastic mitral valve, normal biventricular size, and bilateral SVC (left SVC to CS). Intraoperative finding of aberrant right subclavian artery originating from descending thoracic aorta with retroesophageal course. Patient was palliated in the neonatal period with branch PA bands. Ductal patency maintained with prostaglandin infusion through to definitive surgical repair date.
A redo median sternotomy and extensive dissection was performed. The ascending aorta was 2mm in diameter. There was an anomalous origin of the right subclavian artery from the proximal descending thoracic aorta. The right carotid artery was isolated and anastomosed to a Gore-Tex tube graft. Graft, LSVC, and IVC cannulated and CPB was initiated.
Antegrade cerebral perfusion was initiated. Graft was sewn onto the carotid artery distally enough so that proximal carotid could have the right subclavian artery reimplanted into it. The anomalous right subclavian artery was ligated at its origin with Prolene suture and divided distal to the ligature. It was mobilized from behind the esophagus and trachea. The proximal carotid artery was incised longitudinally along the inferior aspect and the subclavian artery was then anastomosed to the carotid artery in an end-to-side fashion.
Branch PAs were de-banded and gently dilated, thus not requiring patch augmentation.
Ductus was divided. Isthmus was not divided due to absence of posterior shelf. The descending aorta was mobilized, first three sets of intercostal branches taken. Incision completed from divided ductus and continued along underside of aortic arch and lateral ascending aorta. Cutback made to the left of facing commissure in pulmonary root. Damus-Kaye-Stansel was performed. Edge of thoracic aorta and left lateral ascending aorta were joined together. Anterior arch reconstructed with pulmonary homograft.
Secundum ASD was closed. Ventriculotomy performed in right ventricular free wall and enlarged to 15mm. VSD was enlarged superiorly and anteriorly. Pledget-supported sutures placed along inferior rim avoiding injury to tricuspid valve and conduction system. Ends of row were run continuously to complete baffle. Bovine pericardium was used to create LV-to-aorta baffle.
RVOT was reconstructed with 11mm pulmonary homograft with anterior hood of bovine pericardium for proximal securement of conduit to ventriculotomy.
Echo showed good biventricular function, no residual VSD or ASD. There was trivial left and right AV valve regurgitation. There was no LVOTO or obstruction through the RV-to-PA conduit.
