Hybrid Treatment of a Symptomatic Aberrant Right Subclavian Artery (Arteria Lusoria): Radio-anatomical Study and Clinical Application

The aberrant right subclavian artery or arteria lusoria (AL) is the most frequent anatomical variation of the supra-aortic trunks (SAT). The rare symptomatic forms are caused by the compression of the esophagus, the aneurysmal transformation of AL, embolism causing ischemia of the upper limb or posterior CVA. The aim of this work was to establish the theoretical feasibility of a hybrid treatment and its limits with a radio-anatomical study. The secondary objective was to evaluate clinical feasibility. 180 angio-CTs of patients presenting AL were studied. The diameters, the distances and the morphology of SAT were analyzed with the t test using the SPSS22 software. Between 2010 and 2015 all the patients with a symptomatic AL were analyzed. The clinical and anatomical data and the morbi-mortality at D30 and the mid-term results were studied. A diverticulum of Kommerell was present in 112 cases (62%), and a bicarotid trunk in 81 cases (45%). In three cases there was a right sided arch. The latter were analyzed separately. The distance between the right subclavian artery (SCA) and AL was 3.2±6 mm. The distance between the two SCAs was small. To obtain a neck for stentgraft implantation a double transposition (or bypass) was necessary (left common SCA-carotid, right common SCA-carotid) in case of a diverticulum not accessible to embolization. The neck was longer in the presence of a bicarotid trunk. Seven patients (four women; mean age 63 years) were treated for symptomatic AL: dysphagia (1), cerebellar CVA (2), acute upper limb ischemia (1), thoracic pain (1) and rupture (1). Three presented a diverticulum of Kommerell. The treatment consisted in a transposition of AL in the right common carotid (5) with plug embolization (4); debranching of both thoracic SCAs with stentgraft (1); carotido-right SCA bypass with embolization of the AL aneurysm with plug and a thoracic stentgraft (1). The mean duration of follow-up was 28 months (4-66). The primary patency rate and the absence of endoleak reached 100%. One patient underwent an amputation of the forearm for post-ischemic septic complications. The morphometric radio-anatomical study proved the theoretical feasibility of a hybrid treatment and its limits. The hybrid treatment in our clinical experience confirms the radio-anatomical data with good mid-term performances.