Structural aortic arch shift and supraaortic angle configuration changes after subclavian to carotid transposition as a proposed mechanism for relief of severe esophageal compression in aberrant subclavian artery anatomy

Abstract

Objective

– Adult patients with a right-sided aortic arch and aberrant left subclavian artery with a co-existing Kommerell’s diverticulum (KD) can develop clinically significant esophageal compression requiring staged, open, followed by endovascular hybrid repair. No current guidelines exist to guide the surgical treatment of the rare subset of these patients who present without a KD or concomitant aortic arch pathology.

Methods

– a 41-year-old female presented with severe dysphagia and weight loss due to compression of the esophagus by an aberrant left subclavian artery arising from a right-sided aortic arch without distal aortic pathology. There was no evidence of a connective tissue disorder. A left subclavian to carotid transposition was performed through a small left supraclavicular incision. The postoperative computed tomographic images were interpreted by a board-certified staff radiologist.

Results

– The patient did well and follow-up imaging at two months demonstrated patency of the subclavian artery transposition and shifting of the upper mediastinal structures with relief of esophageal compression. At 21 months follow-up the patient had gained 28 pounds and had resumed a normal quality of life.

Conclusion

– Left subclavian to carotid transposition as a singular procedure appears to be a viable treatment option for the adult patient suffering from severe dysphagia resulting from the rare anomaly of an aberrant left subclavian artery arising from a right-sided aortic arch without associated aortic pathology, when combined with lifetime surveillance of the aortic arch. The resulting structural shift in the upper mediastinum resulting in relief of esophageal compression has not been previously reported.