Structural aortic arch shift and supraaortic angle configuration changes after subclavian to carotid transposition as a proposed mechanism for relief of severe esophageal compression in aberrant subclavian artery anatomy

• Aberrant subclavian arteries are uncommon anomalies of the aortic arch often associated with a Kommerell’s diverticulum at the base of the aberrant vessel and aneurysms of the distal arch and descending aorta. • Cases where an aberrant left subclavian artery arising from a right-sided aortic arch without associated aortic pathology produces dysphagia in adults are considered quite rare. • Staged, hybrid repair of aberrant subclavian arteries arising from either a left-sided or right sided arch with a Kommerell’s diverticulum and/or aneurysms of the distal arch or proximal descending thoracic aortic is currently the most commonly employed surgical approach. • Current guidelines for the treatment of symptomatic adult patients with an aberrant left subclavian artery arising from a right-sided arch without associated aortic pathology do not exist. • A subclavian to carotid transposition with very proximal division of the subclavian artery appears to be a viable surgical option in this rare group of patients by producing a shift in the upper mediastinal structures away from the esophagus resulting in relief of compression. – Adult patients with a right-sided aortic arch and aberrant left subclavian artery with a co-existing Kommerell’s diverticulum (KD) can develop clinically significant esophageal compression requiring staged, open, followed by endovascular hybrid repair. No current guidelines exist to guide the surgical treatment of the rare subset of these patients who present without a KD or concomitant aortic arch pathology. – a 41-year-old female presented with severe dysphagia and weight loss due to compression of the esophagus by an aberrant left subclavian artery arising from a right-sided aortic arch without distal aortic pathology. There was no evidence of a connective tissue disorder. A left subclavian to carotid transposition was performed through a small left supraclavicular incision. The postoperative computed tomographic images were interpreted by a board-certified staff radiologist. – The patient did well and follow-up imaging at two months demonstrated patency of the subclavian artery transposition and shifting of the upper mediastinal structures with relief of esophageal compression. At 21 months follow-up the patient had gained 28 pounds and had resumed a normal quality of life. – Left subclavian to carotid transposition as a singular procedure appears to be a viable treatment option for the adult patient suffering from severe dysphagia resulting from the rare anomaly of an aberrant left subclavian artery arising from a right-sided aortic arch without associated aortic pathology, when combined with lifetime surveillance of the aortic arch. The resulting structural shift in the upper mediastinum resulting in relief of esophageal compression has not been previously reported.