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Contemporary Management and Natural History of Aberrant Right Subclavian Artery

Published:November 24, 2021DOI:https://doi.org/10.1016/j.jvs.2021.11.051

      Article Highlights

      • Type of Research: Single-center retrospective study of management of patients diagnosed with aberrant right subclavian artery.
      • Key findings: In a cohort of 30 patients with ARSA, 17 (57%) were women. Twenty (67%) underwent operative repair most commonly due to dysphagia symptoms, Kommerell diverticulum, or concomitant aortic dissection or aneurysmal degeneration at the time of initial presentation. Mean diameter of ARSA at its origin was 20.4 ± 5.7 mm and was not significantly different between the operative versus the initially observed group. Patients initially observed and subsequently intervened upon had the largest change in ARSA cross-sectional diameter 1-cm distal to vessel ostium without significant changes in the cross-sectional aortic-diameters.
      • Take home message: In this cohort, interventions on ARSA were often performed for symptoms (e.g., dysphagia lusoria) or aortic-related complications (e.g., aortic aneurysms degeneration or complicated aortic dissections). Asymptomatic patients with non-aneurysmal ARSA may not require any intervention and maybe safely observed with serial imaging.
      • Table of Contents Summary
      • In this single-center retrospective study, patients with ARSA underwent operative repair most commonly due to dysphagia symptoms, enlarging Kommerell diverticulum, or concomitant aortic dissection or aneurysmal degeneration. Largest change in ARSA cross-sectional diameter was observed 1-cm distal to vessel ostium without significant changes in the cross-sectional aortic-diameters.

      ABSTRACT

      Objective

      Aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch. There is a paucity of literature regarding the management of these patients. The purpose of this study was to evaluate contemporary management strategies and natural history of ARSA in these patients.

      Methods

      A single-center retrospective review of patients diagnosed with ARSA from 2009 to 2019 was performed. CT imaging was analyzed and aortic and ARSA diameters were measured at 10-different segments. Demographic data, comorbidities, and operative interventions were collected. Patients were categorized into those that were intervened upon, and those that were managed expectantly. Linear mixed effect models were used to estimate annual ARSA diameter changes.

      Results

      Thirty patients with ARSA were identified. Seventeen (57%) were female. Average age for the cohort was 54.5 ± 14.6 years. Twenty patients (67%) underwent operative repair at the time of presentation and 10 patients (33%) were initially observed. The most common presenting symptom was dysphagia (30%). Four of the 10 patients, which were initially managed expectantly, subsequently required intervention. Thirteen (13/24, 54%) of the operative interventions performed were hybrid procedures involving right carotid-subclavian bypass or transposition and thoracic endovascular aortic repair (TEVAR). Mean diameter of ARSA at its origin was 20.4 ± 5.7 mm and the mean cross-sectional aortic diameter at the level of ARSA was 31.8 ± 8.5mm for the entire cohort. In patients that were initially observed and subsequently required intervention, the largest change in ARSA cross-sectional diameter was observed 1-cm distal to vessel ostium at a rate of 3.05 mm per year (95% CI [1.54-4.56], p = <0.001). No statistically significant changes in annual growth rate of the aortic segments was observed in the entire cohort or those patients that underwent intervention (p > 0.05).

      Conclusion

      The decision to intervene on an ARSA should be individualized based on presence of symptoms (e.g., dysphagia lusoria) or complications (dissection, concomitant aortic aneurysmal disease, or enlarging Kommerell diverticulum). Asymptomatic patients with non-aneurysmal ARSA may not require any intervention and maybe safely observed. Measurement of cross-sectional ARSA diameter 1-cm distal to the ostium of the vessel might aid in surveillance of vessel diameter changes. Additional studies are needed to determine specific size criteria as an indication for operative repair of asymptomatic KD.

      Keywords

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