Accepted Manuscript Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery Donald G. Harris, MD, Michael E. Huffner, BS, Luqman Croal-Abrahams, BS, Laura DiChiacchio, MD, PhD, Behzad S. Farivar, MD, Joseph D. Ayers, MD, Shahab Toursavadkohi, MD, Joseph Rabin, MD, Robert S. Crawford, MD PII:
To appear in:
Annals of Vascular Surgery
Received Date: 13 July 2015 Revised Date:
12 December 2016
Accepted Date: 19 December 2016
Please cite this article as: Harris DG, Huffner ME, Croal-Abrahams L, DiChiacchio L, Farivar BS, Ayers JD, Toursavadkohi S, Rabin J, Crawford RS, Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.12.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery. Donald G. Harris, MD;1 Michael E. Huffner, BS;1 Luqman Croal-Abrahams, BS;1 Laura
DiChiacchio, MD, PhD;1 Behzad S. Farivar, MD;1 Joseph D. Ayers, MD;2 Shahab
Toursavadkohi, MD;1,3 Joseph Rabin, MD;4 Robert S. Crawford, MD.1,3
7 8 9
1 2 3 4
1. Division of Vascular Surgery, Department of Surgery. University of Maryland School of Medicine. Baltimore, MD. 2. Naval Medical Center San Diego, San Diego, California.
3. Center for Aortic Disease. University of Maryland Medical Center. Baltimore, MD.
4. R Adams Cowley Shock Trauma Center. University of Maryland School of Medicine.
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Blunt thoracic aortic injury (BTAI) in a patient with an aberrant right subclavian artery
(ARSA) presents unique challenges for patient management and aortic repair. Specific
considerations include the need to treat coincidental ARSA, subclavian revascularization, and
ARSA exclusion. Despite the rise of endovascular endovascular repair as the primary modality
for aortic repair for BTAI, reports of this technique in the setting of ARSA are limited. Here we
describe three patients with ARSA who underwent TEVAR for BTAI, and discuss critical
management and technical issues in these patients.
Introduction. Blunt thoracic aortic injury (BTAI) is the second most common cause of death from blunt
trauma, after traumatic brain injury. 1, 2 Recently, the management of patients with BTAI has
been revolutionized by advances in computed tomographic (CT) imaging, adjunctive medical
therapy, selective delayed repair or non-operative management, and the primary use of thoracic
endovascular aortic repair (TEVAR) when intervention is required. 1, 3-7 Together, these have
resulted in a better understanding of the short-term natural history of traumatic aortic lesions, and
enabled management strategies tailored to lesion severity and risk for rupture. 8
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Management of BTAI is more complex in the setting of aberrant aortic anatomy, which
occurs in up to 40% of patients with BTAI. 9 In particular, an aberrant right subclavian artery
(ARSA) originating distal to the LSCA in Zone 3 or 4 may complicate TEVAR for BTAI. 10, 11
ARSA results from abnormal involution of the right fourth aortic arch, an is the most common
congenital aortic arch anomaly, occurring in 0.5 – 2.5% of the general population. 12 An ARSA
may be further complicated by aneurysmal degeneration at the origin, resulting in a Kommerell
Diverticulum (KD) that is at risk for rupture or dissection. 12, 13 Specific challenges in managing
BTAI in the setting of an ARSA include achieving complete BTAI isolation, treatment of
concurrent KD, and maintenance of posterior cerebral circulation. Here we describe three
patients with ARSA and BTAI to illustrate the management of these issues.
Among 120 patients with BTAI between 2009 – 2014 at a major Level I trauma center,
three (2.5%) had ARSA. Institutional practice includes screening CT angiography for patients at
risk for BTAI. Patients with BTAI are managed in consultation with a joint cardiac and vascular
aortic injury team, and preoperative medical therapy includes β-blockade and medical adjuncts to
achieve a systolic blood pressure ≤ 120 mmHg, a mean arterial pressure ≤ 80 mmHg, and heart
rate between 60 – 80 beats/min. TEVAR is performed in a standard fashion. Percutaneous
femoral catheterization is obtained for guidewire and pigtail catheter access of the aortic arch.
Contralateral open or percutaneous femoral access is obtained for cannulation with an introducer
sheath, arch access with a Lunderquist wire, and endograft deployment. Routine preoperative
subclavian revascularization is not performed in patients who may require LSCA coverage. 5
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57 Patient 1.
A 57 year old woman was admitted in 2009 after a motorvehicle collision, having
sustained blunt thoracic and spinal injuries. An admission CT angiogram demonstrated a
common arch origin of the right and left carotid arteries, and a 5 mm ARSA with a 13 mm KD
located 10 mm distal from the LSCA. A further 20 mm distal from the ARSA was a 38 mm
traumatic pseudoaneurysm with moderate mediastinal hematoma (Figure 1). TEVAR was
performed on hospital day two using three Gore Excluder aortic cuffs deployed in the descending
thoracic aorta starting just distal to the ARSA (Figure 2); given the urgent nature of the
procedure and the limited size of the KD, further intervention to address the ARSA was not
pursued. The patient was discharged on hospital day 49 after recovering from concurrent
injuries. A CT angiogram obtained six months after repair demonstrated exclusion of the
pseudoaneurysm and stable KD. At latest follow-up five years after surgery the patient was
Patient 2. A 27 year old man was admitted with thoracic and extremity injuries in 2012 after a
motorvehicle collision. On admission CT angiogram, the patient had a 29 mm traumatic
pseudoaneurysm arising 18 mm from the LSCA. Just proximal to the injury was a 7 mm ARSA
that neither involved the pseudoaneurysm nor had a diverticulum (Figures 3, and 4a & b). The
left vertebral artery was dominant and arose from the LSCA, while the right vertebral artery
arose from the right carotid artery. The patient underwent TEVAR on hospital day two, with
deployment of a Gore TAG endograft just distal from the LSCA, covering the ARSA origin in
order to achieve a sufficient proximal landing zone (Figure 4c). Because the ARSA had no
aneurysmal degeneration and did not communicate with the aortic injury, embolization was not
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Afterwards, the patient lost his right radial and ulnar pulses, but had biphasic Doppler
waveforms and no symptoms of arm ischemia. A postoperative CT angiogram demonstrated
exclusion of the traumatic pseudoaneurysm and collateral filling of the ARSA (Figure 4d). He
was discharged on hospital day 5, and upon follow-up one month after injury had regained his
right radial and ulnar pulses.
In 2014 a 27 year old man presented after a motorcycle crash with extensive leg and chest
injuries. On CT angiography he had a symmetric vertebral arteries arising from the ARSA and
LSCA, and an 11 mm wide ARSA with a diverticulum arising 18 mm distal from the LSCA.
Near the ARSA origin arose a complex, 27 mm traumatic pseudoaneurysm (Figure 5). On
hospital day two he underwent TEVAR with deployment of a Medtronic Valiant thoracic graft
distal to the LSCA, covering the ARSA and pseudoaneurysm. Because the wide origin of the
ARSA communicated with the pseudoaneurysm, the proximal ARSA was embolized via
retrograde right brachial access with with Amplatzer vascular plugs at the origin of the ARSA
and the distal ARSA to the right of the esophagus(Figure 6). Postoperatively the patient had right
finger digital pressures of 65 mmHg versus 135 on the left, but had no symptoms of extremity or
Aberrant aortic anatomy is common among patients with BTAI, and may be a risk factor
for aortic injury. 9, 14 Further, ARSA may complicate otherwise frequently routine endovascular
treatment of BTAI. The three patients described in this report illustrate several important
concepts for managing patients with ARSA and BTAI, particularly the role for ARSA
intervention, revacularization, and exclusion.
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Aberrant right subclavian artery is usually clinically occult, and an incidental finding
during thoracic imaging studies. Indeed, as illustrated by Patient 1, in certain situations of ARSA
and BTAI, the ARSA may not complicate aortic intervention. This patient had a sufficient
landing zone between her ARSA and traumatic pseudoaneurysm to enable a proximal seal
without covering the ARSA. Although a KD was present, it was much smaller than the 3 cm
recommended as a threshold for intervention, 15 and could be treated on an elective basis should
it enlarge. As such, if there is no significant KD and TEVAR can be performed without ARSA
coverage, the ARSA requires no further immediate management.
In patients in whom ARSA coverage is required, revascularization of the right subclavian
needs to be considered and depends on several factors. First, a dominant right vertebral artery
arising from the ARSA warrants revascularization, preferably preoperatively unless the BTAI is
unstable. 5, 10 If the right vertebral artery has a variant origin or is non-dominant, the ARSA can
be covered if needed to achieve a proximal seal during BTAI exclusion. In this scenario, similar
to coverage of the LSCA in patients with BTAI and normal arch anatomy, which is frequently
covered without consequence, 3, 16 subsequent revascularization can be selective. 10, 17 As Patients
2 and 3 demonstrated, and consistent with LSCA experience and other ARSA reports, ARSA
coverage can be well tolerated without revascularization.
insufficient distance between the LSCA and BTAI for a proximal seal, coverage of both the
ARSA and LSCA may be required. 10 Depending on vertebral artery anatomy and dominance,
this warrants revascularization of at least one and potentially both subclavian arteries. 10, 18
However, in patients with
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Endovascular coverage and exclusion of the origin is the most complete treatment of
ARSA in patients undergoing TEVAR for concurrent BTAI. ARSA exclusion via retrograde
right subclavian access and embolization is indicated for two potential scenarios. First, in
patients with a large KD that warrants repair (≥ 3 cm), 15 TEVAR and exclusion definitively
treats the KD. Similarly, this may be considered for patients with a moderate KD and potentially
poor follow-up. Second, as for Patient 3, an ARSA origin that is involved by a traumatic
pseudoaneurysm requires embolization to completely exclude the aortic injury. Given that the
ARSA origin is more prone to degeneration than normal aortic branch arteries, coverage and
exclusion could also be considered for lower aortic grade injuries that may otherwise be safely
managed non-operatively. To treat or prevent esophageal symptoms or complications,
embolization of the ARSA is performed at its origin and to the right of the esophagus,
decompressing the segment that is in apposition to the esophagus.
Conclusion. The presence of ARSA in the setting of BTAI complicates routine aortic repair.
Depending on the location of the ARSA, vertebral artery anatomy, presence of a KD, and
involvement with the aortic injury itself, ARSA coverage, exclusion, and distal revascularization
need to be considered. ARSA coverage without revascularization is tolerated in appropriately
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Figure I. Admission CT of Patient 1.
202 A & B: Retroesophageal ARSA (block arrow) with it’s origin from the distal arch with a
Kommerell diverticulum. A common origin of the right and left carotid arteries are
coincidentally noted. C & D: Traumatic pseudoaneurysm (asterix) of the proximal descending
thoracic aorta with moderate mediastinal hematoma. E: Sagittal reconstruction of the arch and
thoracic aorta demonstrating a common carotid origin, LSCA, Kommerell diverticulum at the
ARSA origin, and aortic injury.
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Figure II. Intraoperative angiography and postoperative CT of Patient 1.
A: Initial arch angiogram demonstrating a common origin of the right and left carotid arteries,
LSCA, and ARSA arising and coursing posterior to the arch (block arrow). The traumatic
pseudoaneurysm is 2 cm distal from the ARSA (asterix). B: Completion angiogram after
endograft deployment demonstrating a patent ARSA and excluded pseudoaneurysm. C: Sagittal
reconstruction of the postoperative CT demonstrating the arch vessels, ARSA, and endograft.
Figure III. Admission CT of Patient 2.
A – C: Retroesophageal ARSA (block arrow) arising from the distal arch near, but not involving
the traumatic pseudoaneurysm (asterix). D & E: Sagittal reconstruction demonstrating the
relationships of the LSCA, ARSA, and pseudoaneurysm.
Figure IV. Intraoperative angiography and postoperative CT of Patient 2.
225 A & B: 40° left anterior oblique 69° right anterior oblique arch angiograms demonstrating ARSA
(block arrow) arising from the posterior aortic arch opposite the traumatic pseudoaneurysm. C:
Postoperative CT demonstrating proximal endograft landing just distal from the LSCA. D:
Postoperative CT demonstrating opacification of the excluded ARSA.
Figure V. Admission CT of Patient 3.
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A & B: Demonstration of the wide ARSA with 18 mm Kommerell diverticulum (block arrows).
C & D: Communicating with the distal aspect of the diverticulum was a complex, moderately
sized traumatic pseudoaneurysm (asterix). E – H: Coronal and sagittal reconstructions
demonstrating the proximity of the ARSA and diverticulum to the aortic injury.
Figure VI. Intraoperative angiography and postoperative CT of Patient 2.
A: Exclusion of the ARSA origin and traumatic pseudoaneurysm after deployment of Amplatzer
vascular plugs in the proximal ARSA. B – D: Postoperative CT images and 3-D reconstruction
demonstrating the TEVAR and vascular plugs with ARSA and traumatic pseudoaneurysm
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