Background and Aims: Aberrant right subclavian artery (ARSA) is one of the congenital anomalies of the aortic arch. Stanford type B aortic dissection (TBAD) combined with ARSA is extremely rare and life-threatening. Most of them previously were treated by means of conventional open surgery or hybrid operation. With the rapid development of endovascular techniques, thoracic endovascular aortic repair (TEVAR) is being increasingly used in the treatment of TBAD associated with ARSA, which has the advantages of minimal invasive and fast postoperative recovery. Due to the uncertainty of the relative locations of ARSA to the primary entry tear of the TBAD, how to deal with ARSA and primary entry tear must be taken into serious consideration. The efficacy and safety of total endovascular treatment of this complex condition of the aortic arch are uncertain. Therefore, this study was conduct to investigate endovascular repair for TBAD with ARSA, and provide the preliminary experience. 
Methods: The clinical data of 16 patients with TBAD and combined ARSA undergoing TEVAR in the Second Xiangya Hospital of Central South University from January 2012 to December 2019 were retrospectively analyzed. Of the patients, 14 cases were males and 2 cases were females, with an average age of (56±11.3) years; the primary entry tear located in zone 3 in 13 cases, and located in zone 4 in 3 cases; left vertebral artery dominance presented in 14 cases, right vertebral artery dominance was found in 1 case and 1 case had equipotent bilateral vertebral arteries. Personalized operative plans were made according to the locations of the primary entry tear and the opening of bilateral subclavian arteries as well as the pattern of the vertebral arteries.
Results: The technical success rate was 100%. The mean operative time was (95.2±38.9) min. There was no perioperative mortality. The blood flow of bilateral subclavian arteries was preserved in 3 patients, 5 cases underwent covering of the ARSA, chimney technique was used in 7 patients to preserve the left subclavian artery (LSA), both chimney and periscope techniques were used in one patient to reconstruct the ARSA, and fenestration technique was used in one patient to reconstruct the LSA. Patients undergoing reconstruction of the branches of the aortic arch were administered with aspirin (100 mg/d) and clopidogrel (75 mg/d) for 3 months after operation. The mean follow-up time was 33.2 (3–66) months. No endoleak or stent graft migration occurred; right upper limb ischemia occurred in 2 patients, which recovered gradually after conservative treatment; the comparison between preoperative CTA and the last follow-up CTA showed that the mean maximum diameter of the descending aorta was decreased from (37.1±9.6) mm to (33.9±8.9) mm, and the false/true lumen ratio was decreased from 1.03±0.62 to 0.21±0.31. During long-term follow-up, all of the chimney stent grafts were patent, and none of the patients developed symptoms such as ischemia of the branch arteries of the aortic arch, subclavian steal syndrome and spinal cord ischemia.
Conclusion: TEVAR combined with chimney or fenestration technique is safe and feasible for TBAD with ARSA, by which, the primary entry tear of the aortic dissection can be effectively covered with simultaneous preservation of the blood flow of the LSA and (or) ARSA, with the advantages of quick recovery, short of hospitalization and low incidence of perioperative complications. The specific operative procedure should be based on the relative locations of ARSA to the primary entry tear, and ensure at least the blood flow of the ipsilateral subclavian artery giving rise to the dominant vertebral artery.