Characterization and Surgical Management of the Aberrant Subclavian Artery.

OBJECTIVES: Aberrant subclavian arteries (aSCA), with or without aortic pathology are uncommon. The purpose of this study is to review our experience with surgical management of aSCA.

METHODS: We performed a retrospective review of patients who underwent surgery for aSCA between 1996-2020. Symptomatic and asymptomatic patients were included. Primary endpoints were ≤ 30 day and late mortality. Secondary endpoints were ≤ 30-day complications, graft patency, and re-interventions.

RESULTS: Forty-six symptomatic and 3 asymptomatic patients with aSCA underwent surgical treatment (female: 31, 62%; median age 45 years). Aberrant right subclavian artery (aRSCA) was present in 38 (78%), and aberrant left subclavian artery (aLSCA) in 11 (22%). Forty-one (84%) had a Kommerell diverticulum (KD) and 11(22%) had concomitant distal arch or proximal descending thoracic aortic (DA/PDTA) aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia in (20%), and upper extremity exertional fatigue in (16%). Five patients (10%) required emergency surgery. The aSCA was treated by transposition in 32, carotid to subclavian bypass in 11 and ascending aorta to subclavian bypass in 6. KD was treated by resection and oversewing in 19 (39%). Fifteen (31%) required DA/PDTA replacement for concomitant aortic disease and/or KD treatment. TEVAR was used to exclude the KD in 6 (12%). Seven patients (14%) had only bypass or transposition. 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. 30-day major complications (14%) included acute respiratory failure in 3, early mortality in 1, stroke in 1, NSTEMI in 1, and 1 temporary dialysis in 1. Others included 5 (10%) chylothorax/lymphocele, 2 (4%) acute kidney injury (AKI), 2 (4%) pneumonia, 2 (4%) wound infection, 2 (4%) atrial fibrillation, 2 (4%) Horner syndrome, 1 (2%) lower extremity acute limb ischemia (ALI) and 1 (2%) left recurrent laryngeal nerve injury. At median follow up of 53 months (range 1-230), 40 (80%) patients had complete symptom relief and 10 (20%) had improvement. Six late deaths occurred at a median of 157 months and were not procedure or aortic related. Primary patency was 98%. ≤ 30-day re-interventions occurred in 2 (4%) for ligation of lymphatics and bilateral lower extremity fasciotomy after proximal DTA replacement. One patient required late explant of an infected and occluded carotid to subclavian bypass graft; treated by cryopreserved allograft replacement.

CONCLUSIONS: Surgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief.