Elizabeth H. Stephens, M.D., Ph.D. , a pediatric and congenital cardiac surgeon at Mayo Clinic in Rochester, Minnesota, describes the surgical repair strategy for adults with vascular rings — specifically, right aortic arch and aberrant left subclavian.
This technique, developed by Alberto Pochettino, M.D. , and Thomas C. Bower, M.D., involves two stages:
Transposition of the subclavian artery to the carotid via an incision in the neck
Replacement of the aortic segment containing the Kommerell's diverticulum via a right thoracotomy
Dr. Stephens explains the technique using diagrams and operative footage in the context of two clinical cases.
My name is Elizabeth Stephens. I am a pediatric and congenital heart surgeon and Mayo Clinic. In this video, we illustrate the operative management of adult Vassar rings, specifically right arch with aberrant left subclavian artery. We will show two cases with operative footage. For examples, this illustrates the anatomy. We're looking from the left chest and can see the airway, esophagus and the aorta heading behind the airway and esophagus into the right chest. In the foreground, we see the ligament, um, and aberrant left subclavian artery with the cameras diverticular, um, causing compression in terms of repair, we will be showing the technique developed by doctors Bauer and Pochettino, in which the left subclavian artery is transferred onto the left common carotid artery via a super clavicle er incision. And then, in the second stage, the portion of the aorta with the cameras. Diverticular um is replaced with a to graft dia right thoracotomy on partial cardiopulmonary bypass. In this first case, the patient is a 21 year old female competitive basketball player who was noted to have a murmur which prompted an echo. This eco demonstrated abnormal branching of the head vessels, which led to a C T scan that demonstrated a right art with aberrant left subclavian, artery and cameras diverticular. Upon further inquiry, she noted to have longstanding respiratory difficulties and dysplasia. Here is the three D reconstruction of a CT scan demonstrating her anatomy. You can appreciate the aberrant subclavian and cameras diverticular. Um, Now we're looking down the barrel and you can see the ring narrowing the airway and esophagus. In this first stage of the repair, the head is at the top of the screen and we're making a small left super co vehicular incision. We're now dissecting free the left common carotid. Here, we're putting a vessel loop around the Karate Kid. Now we're dissecting free the subclavian artery. We're marking where the NASA Moses with the subclavian will go, which is relatively lateral on the karate here, the NASA Moses is being completed. The other end of the subclavian has been over soon. Here is the completed anastomosis. This diagram illustrates the second stage of the repair through a right through our economy. The anatomy is labeled with the cameras diverticular coming off the aorta, the right subclavian which will need to be clamped during the repair and then the as Vegas, Spain, and Superior Ben Akiva. This next diagram shows the arterial anatomy as viewed from a right thoracotomy. You can appreciate the cameras diverticular, um, again the rights of plebian artery and the left subclavian curated anastomosis performed in the neck during stage one. This is the inter operative anatomy. The head is still left on the screen and we have now performed a right thoracotomy, having notch one rib above and below the thoracotomy. You can see the descending aorta, the as it gets being crossing and the superior vena cava, the as a guest. Spain is being divided for exposure, and the proximal as August can be used for calculation into the superior vena cava. We're now dissecting out the aortic arch. Ah, blew vessel loop is around the right subclavian artery, and that is being dissected free. The aorta is now being sized, and a 20 millimeter graft was chosen. We use a cell dinger technique for descending aortic cannula ation with the 18 French fem flux cannula. Here we're putting in the Venus cannula in the superior vena cava. This is a pediatric 26 French angle cannula and the purse string can be on the proximal as Argus or the SBC itself, without need to enter the pericardial cavity. Now we're putting a clamp on the rights of Kleban artery. Now we're clamping the descending aorta and now clamping the aortic arch. The superior portion of the graft is now being suited in place using four Oprah lean. We're now suit during the interior wall. The clamp on the arch has been moved to the graft and felt in mattress repair. Suitors have been placed as needed. Here is the remnant aorta, and you can get a sense of the pouch of the cameras diverticular um, extending post eerily as also shown in this still frame. Now we're doing the inferior aortic anastomosis. Here's the front wall of the graft anastomosis. Here is the final result and the patients postoperative CT scan. The second case is that of a 62 year old gentleman with worsening upper airway symptoms and dysplasia. A C T scan demonstrate the same vascular ring anatomy, namely right sided arch with aberrant left subclavian and cameras. Diverticular. Um, here is the C T scan demonstrating a severely dilated cameras. Diverticular um, an aneurysm, all dilation of his descending aorta. Here is a three D reconstruction of that C T skin and Asafa Graham demonstrated narrowing and deviation of the esophagus to the left. Here we are already on partial bypass and we're transacting the proximal descending aorta. You can appreciate the large cameras diverticular extending posterior early, given the aneurysm all dilation of the descending aorta of this patient. A more extensive aortic replacement was performed down to distal aorta with more normal diameter and tissue quality. The proximal and distal and nasty Moses are performed as in the last case, and here is the final result. Here is the post operative three D reconstruction of the C T scan. This is a short summary of a complex Operation oven unusual anomaly that we may have obtained substantial experience in. We hope that you have found this video helpful. Please visit our other male YouTube videos as well as our website for further information
