A 10-Year Experience Using a Hybrid Endovascular Approach to Treat Aberrant Subclavian Arterial Aneurysms.

BACKGROUND: The aim of the study was to describe a single-center experience using combined extra-anatomic open arch branch revascularization with aortic arch endovascular exclusion for treatment of aberrant subclavian artery aneurysms.

METHODS: All patients undergoing management of aberrant subclavian aneurysms were identified from a prospective patient registry. Means of revascularization included carotid-subclavian bypass or subclavian transposition, and origin occlusion was performed by surgical ligation or endovascular embolization at surgeon discretion. Completion of aneurysm exclusion was performed using available distal arch/thoracic aortic endografts (TEVARs) using standard oversizing. Procedures were staged as appropriate based on patient condition.

RESULTS: Ten patients, 8 females and 2 males ranging from 32 to 85 years of age, were identified. Presenting symptoms were dysphagia (n = 9) and acute type B aortic dissection (n = 1). All patients required revascularization/exclusion of bilateral subclavian arteries to enable >20 mm proximal aortic fixation distal to the common carotid origins for the arch endograft. TEVAR with planned coverage of both subclavian origins extending into the proximal descending thoracic aorta was performed using transfemoral access (n = 9) or iliac conduit (n = 1) and required a single device (100-157 mm) in all cases except the aortic dissection which required total length coverage of the descending thoracic aorta. Extra-anatomic revascularization and thoracic endografting were staged by 1-2 days in most cases to minimize potential airway edema from bilateral neck exposures. Subclavian revascularization was performed by carotid-subclavian bypass using polytetrafluoroethylene (n = 17) or subclavian transposition (n = 3) with proximal occlusion using embolization with an Amplatzer II plug (n = 11) or ligation (n = 9). No major complications occurred including spinal cord ischemia, stroke, cranial nerve deficit, arm ischemia, access site complications, or wound complications. Length of stay ranged from 6 to 21 days with all patients having resolution of dysphagia on follow-up (mean 41 months). Directed imaging was available for 7 patients demonstrating the absence of endoleak, regression or stability of aneurysm size, and patency of all subclavian revascularizations.

CONCLUSIONS: We present a hybrid repair technique with low operative morbidity that has shown to be durable in follow-up and to provide symptomatic relief for patients with aberrant subclavian artery aneurysms causing esophageal compression.