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Robotic-Assisted Treatment of Aberrant Retroesophageal Right Subclavian Artery
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posted on 2021-04-22, 20:25 authored by G. Kimble Jett, Lee Hafen, Anthony Tran, William ShutzeAberrant
right subclavian artery (ARSA) is a rare anomaly but is the most common
congenital abnormality of the aortic arch with an incidence of 0.3-3.0% (1, 2).
The vessel embryologically is the 4th branch of the aortic arch, most commonly
passes behind the esophagus and crosses the midline between the esophagus and
the vertebral column to reach the right arm (3). Approximately 60% may be
aneurysmal at their origin (4). An aberrant right subclavian artery may be
asymptomatic or can produce dysphagia (dysphagia lusoria), chest pain,
shortness of breath or chronic cough.
Treatment of ARSA is indicated for symptomatic relief and for the prevention of
aneurysmal dilatation and complications resulting from the aneurysm (5).
Surgical treatment usually involves division of the subclavian artery at its
origin. The classic approach involves a left thoracotomy (6) although other
surgical approaches have been described including right thoracotomy (7),
right-sided supraclavicular incision (8), and hybrid procedure with thoracic
endoluminal graft exclusion (9). Recently robotic assisted resection has been
described (10).
Restoring pulsatile blood flow to the right arm has been debated. Some advocate
that revascularizing the subclavian artery is imperative (9). A published
review demonstrated only 14% of patients who did not undergo revascularization
following surgical treatment of ARSA developed limb ischemia (11). A case
report demonstrated a patient did well without revascularization with
intermittent weakness and numbness of his right arm until his death 11 years
later (12).
This video demonstrates the technique of robotic assisted division of an aberrant retroesophageal right subclavian artery utilizing a right-sided approach. The patient is a 37-year-old with a history of chest pain and dysphagia. CTA of chest demonstrated an aberrant retroesophageal right subclavian artery (ARSA). The esophagus was effaced at the level of the vessel. The left subclavian had its origin near the right subclavian, and it was felt that endoluminal graft exclusion of the right subclavian artery could not be accomplished without also excluding the left subclavian. The aberrant right subclavian artery was stapled at its origin freeing the entrapped esophagus. The right arm was not revascularized. The patient was discharged home on the 1st postoperative day. Follow-up demonstrated a warm right arm with a weak right radial pulse. There was intermittent right arm fatigue, but no paresthesias. The patient’s dysphagia had completely resolved. CTA on follow-up demonstrated flush division of the right subclavian artery with excellent collateral flow to the subclavian and vertebral arteries. There was no esophageal narrowing or effacement. The right-sided approach offered excellent exposure of the aberrant artery allowing division at its origin from the aorta. In addition, the robotic approach offers improved vision and a stable platform resulting in reduced pain, hospital length of stay and enhance patient recovery time.
This video demonstrates the technique of robotic assisted division of an aberrant retroesophageal right subclavian artery utilizing a right-sided approach. The patient is a 37-year-old with a history of chest pain and dysphagia. CTA of chest demonstrated an aberrant retroesophageal right subclavian artery (ARSA). The esophagus was effaced at the level of the vessel. The left subclavian had its origin near the right subclavian, and it was felt that endoluminal graft exclusion of the right subclavian artery could not be accomplished without also excluding the left subclavian. The aberrant right subclavian artery was stapled at its origin freeing the entrapped esophagus. The right arm was not revascularized. The patient was discharged home on the 1st postoperative day. Follow-up demonstrated a warm right arm with a weak right radial pulse. There was intermittent right arm fatigue, but no paresthesias. The patient’s dysphagia had completely resolved. CTA on follow-up demonstrated flush division of the right subclavian artery with excellent collateral flow to the subclavian and vertebral arteries. There was no esophageal narrowing or effacement. The right-sided approach offered excellent exposure of the aberrant artery allowing division at its origin from the aorta. In addition, the robotic approach offers improved vision and a stable platform resulting in reduced pain, hospital length of stay and enhance patient recovery time.
