Successful open stent grafting of a right aortic arch and a descending aortic aneurysm originating from a Kommerell's diverticulum: report of a case

Single-Stage Total Arch Replacement With Open Stent Graft for Kommerell's Diverticulum With Right-Sided Aortic Arch

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

A review of the surgical management of right-sided aortic arch aneurysms

Aneurysms and dissections of the right-sided aortic arch are rare and published data are limited to a few case reports and small series. The optimal treatment strategy of this entity and the challenges associated with their management are not yet fully investigated and conclusive. We performed a systematic review of the literature to identify all patients who underwent surgical or endovascular intervention for right aortic arch aneurysms or dissections. The search was limited to the articles published only in English. We focused on presentation and critically assessed different management strategies and outcomes. We identified 74 studies that reported 99 patients undergoing surgical or endovascular intervention for a right aortic arch aneurysm or dissection. The median age was 61 years. The commonest presenting symptoms were chest or back pain and dysphagia. Eighty-eight patients had an aberrant left subclavian artery with only 11 patients having the mirror image variant of a right aortic arch. The commonest pathology was aneurysm arising from a Kommerell's diverticulum occurring in over 50% of the patients. Twenty-eight patients had dissections, 19 of these were Type B and 9 were Type A. Eighty-one patients had elective operations while 18 had emergency procedures. Sixty-seven patients underwent surgical treatment, 20 patients had hybrid surgical and endovascular procedures and 12 had totally endovascular procedure. There were 5 deaths, 4 of which were in patients undergoing emergency surgery and none in the endovascular repair group. Aneurysms and dissections of a right-sided aortic arch are rare. Advances in endovascular treatment and hybrid surgical and endovascular management are making this rare pathology amenable to these approaches and may confer improved outcomes compared with conventional extensive repair techniques.

Endovascular treatment of acute type B dissection and Kommerell's diverticulum

A 59-year-old man presented with severe hypertension and resistant interscapular pain. Transesophageal echocardiography and computed tomographic angiogram demonstrated acute type B dissection associated with aberrant right subclavian artery with 3.5 cm Kommerell's diverticulum. Open repair was deemed to be high risk to elevate perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical therapy because of resistant thoracic pain. We did not observe intraoperative or perioperative mortality and right arm ischemia or symptomatic subclavian steal.

Surgical treatment for Kommerell’s diverticulum

OBJECTIVE

Kommerell's diverticulum, which is a rare condition, is a congenital abnormality of the aortic arch. The strategy of surgical treatment for Kommerell's diverticulum has not been established.

METHODS

Between 1994 and 2004, 6 patients underwent surgery for Kommerell's diverticulum at our institute. Diagnoses included right aortic arch with aberrant left subclavian artery in 4 patients and left aortic arch with aberrant right subclavian artery in 2 patients. Indications for surgery were dilatation of Kommerell's aneurysm (n = 4) and dysphagia (n = 2). One patient underwent total arch replacement through the median sternotomy plus right thoracotomy. Five patients underwent replacement of the descending aorta and reconstruction in situ (n = 4) or ligation (n = 1) of the stenotic aberrant subclavian artery through the right (n = 3) or left (n = 2) thoracotomy.

RESULTS

There were no patient deaths or patients who required rehospitalization. Mediastinitis occurred in 1 patient. This patient required mediastinal drainage and an omentopexy. Two patients who had dysphagia became asymptomatic. Postoperative angiographies in all patients were satisfactory. The patient whose aberrant subclavian artery was ligated had no ischemic symptom of the arm. At the midterm outcomes (mean follow-up length was 55.6 +/- 42.2 months, ranging 10-114 months), all patients resumed normal activities without any complications.

CONCLUSIONS

Kommerell's diverticulum can be repaired safely with graft replacement concomitant with in situ reconstruction of the aberrant subclavian artery through thoracotomy.