https://orcid.org/0000-0001-7947-3473
Abstract
A 69-year-old female suffering from severe dysphagia due to an aberrant right subclavian artery was treated with a two-step approach. A right carotid-subclavian bypass was followed 2 weeks later by a robotic-assisted thoracoscopic resection of the aberrant right subclavian artery. The postoperative course was uneventful, and the patient immediately recovered from her dysphagia. In our case, the robotic-assisted technology offered major advantages and, based on our experience, may be useful in the treatment of this rare disease.
INTRODUCTION
An aberrant right subclavian artery (ARSA) is a rare but known cause of dysphagia due to its typical retro-oesophageal course [1]. The treatment of symptomatic cases ranges from conservative to surgical to endovascular, whereas endoscopic approaches have been reported in high-risk patients [2, 3].
CASE REPORT
A 69-year-old female patient without comorbidities developed untreatable cough and dysphagia associated to weight loss over the past 6 months. A contrast-swallow study showed a left-sided indentation of the oesophagus just above the aortic arch. The extrinsic compression was confirmed by an oesophagogastroduodenoscopy and the computed tomography (CT) angiography revealed the presence of an ARSA, originating from the aortic arch distally to the left subclavian artery. The artery was dilated only at the origin (14 mm) and had an 8-mm calibre within its retro-oesophageal course (Fig. 1).
Multiplanar reconstruction of the computed tomography scan showing the oesophageal compression due to the arteria lusoria.
As a first step, a supra-aortic debranching with right carotid-subclavian bypass (7-mm Dacron) and ligature of the ARSA proximally to the vertebral artery was performed (Fig. 2). After an uneventful postoperative course, the patient kept on the complaining of severe dysphagia. The CT angiography showed a thrombosed ARSA up to the origin.
Intraoperative image showing the anastomosis on the common carotid artery during the supra-aortic debranching.
In a second step, three 8-mm and one 12-mm trocars were inserted in the left-sided decubitus, and the DaVinci Xi robotic system (Intuitive Surgical) was docked. The azygos vein was divided, and the oesophagus mobilized to identify the ARSA. After complete preparation, the artery was clipped with Hem-o-lok 15 mm (four proximally and one distally) and resected (Video 1). The postoperative course was uneventful, and the patient had a full recovery from her dysphagia.
Robotic-assisted thoracoscopic view demonstrating the resection of an aberrant right subclavian artery.
DISCUSSION
The dysphagia lusoria is a well-known cause of swallowing impairment [2]. An ARSA is often diagnosed incidentally with a CT scan, which is symptomatic in 20–40% of patients only [1, 2]. Dietary modification, prokinetic drugs and protonic pump inhibitors represent possible conservative measures [2]. Surgical approaches with thoracotomy or sternotomy have been described; however, the reported mortality rate was up to 23% [3]. With less invasive approaches, the short-term mortality has been reported to be lower [3, 4]; nonetheless, not resecting the ARSA may lead to severe symptoms persistence for months, requiring patients to be fed with liquid diet or naso-gastric tube.
In our case, with an 8-mm ARSA and severe dysphagia, the robot-assisted, thoracoscopic resection proved to be a valuable treatment option after supra-aortic debranching.
Thanks to advantages of robotic-assisted technology, the optimal field view permitted an accurate and safe mobilization of the upper thoracic oesophagus and ARSA dissection, otherwise achievable with a sternotomy or thoracotomy [5]. The preparation and closure of the vessel’s origin was the most challenging part of the operation and was performed without complications. The closure of the ARSA with clips was feasible and safe, thanks to the adequate calibre and wall integrity. The same manoeuvre might be extremely hazardous in patients with ARSA aneurysm due to the risk of arterial wall injury and major bleeding. A thoracoscopic vascular stapler might represent an option. For the same reason, the presence of a back-up team capable of stent graft deployment (as first option) and cardiothoracic surgery is mandatory in case such a complication occurs.
The robotic-assisted approach may be taken into account as an option in a patient-tailored concept to treat symptomatic ARSA. Of course, patients with underlying connective disease and aneurysmatic aorta dilatation should be treated differently, prioritizing the underlying disease [5]. Nevertheless, robotic surgery can be seen as a minimally invasive alternative in case of a favourable anatomy.
CONCLUSIONS
In our case, the robotic-assisted technology offered major advantages to resect an ARSA following a typical supra-aortic debranching. This approach can be an option in selected patients with a favourable vascular anatomy and presence of a back-up team.
Conflict of interest: none declared.
Reviewer information
European Journal of Cardio-Thoracic Surgery thanks Michael Jacobs and Jürg Schmidli for their contribution to the peer review process of this article.
