Two-stage surgical treatment of Stanford type B acute aortic dissection associated with aberrant right subclavian artery dissection complicated by distal arch aortic aneurysm and abdominal aortic aneurysm: a case report

An aberrant right subclavian artery (ARSA) is the most common congenital variant of the aortic arch and occurs in 0.5–1.8% of the population. Most patients with ARSA remain asymptomatic; however, symptoms associated with ARSA include dysphagia, esophageal compression, and airway obstruction. Surgical intervention is indicated if the ARSA becomes symptomatic or is related to aneurysmal dilatation. Even without symptoms, it carries the risk of rupture or dissection, and aggressive surgical therapy is recommended. The coexistence of type B dissection and ARSA is relatively rare, and the cause of this anomaly is unclear; however, some authors have reported that the acute angle of the ARSA weakens the aortic wall, inducing aortic dissection. Several surgical methods, such as thoracic endovascular aortic repair (TEVAR), the frozen elephant trunk method, and open surgery, have been used to manage this lesion. Reconstruction of ARSA is challenging in any surgical procedure.

We present an uncommon case of coexistent type B aortic dissection and aberrant right subclavian artery (ARSA) in a 72-year-old man. Left anterolateral thoracotomy was chosen to treat the enlarged descending thoracic aortic aneurysm in this case; in situ reconstruction was difficult because the dissection involved the ARSA. Hence, preoperatively, a right common carotid artery (RCCA)-to-ARSA bypass was performed via the right supraclavicular approach, followed by thoracic descending aortic artery reconstruction. The prior RCCA-to-ARSA bypass allowed ligation of the central side of the ARSA, thereby securing a bloodless field in the distal anastomosis.

This lesion can be successfully repaired by open surgery with a two-stage approach: right common carotid artery-to-ARSA bypass followed by thoracic aortic replacement.