Kommerell Diverticulum Should Be Removed in Children With Vascular Ring and Aberrant Left Subclavian Artery

Vascular rings - what has changed, and what do I need to know as a practitioner?

Vascular rings represent a heterogeneous set of aberrant great vessel anatomic configurations which can cause respiratory symptoms or dysphagia due to tracheal or oesophageal compression. These symptoms can be subtle and may present at varied ages. More recently, many have been identified in patients without symptoms, including fetal echocardiogram, resulting in a conundrum for practitioners when attempting to determine who will benefit from surgical correction. Here, we provide a review of vascular rings and a guide to the practitioner on when to consider additional imaging or referral. Additionally, we discuss the changing landscape regarding asymptomatic patients and fetal echocardiogram.

Aortopexy With Plication of Kommerell Diverticulum is an Effective Alternative to Diverticulum Resection and Reimplantation of the Aberrant Left Subclavian Artery for Surgical Management of Vascular Rings in Children

BackgroundRight aortic arch with an aberrant left subclavian artery arising from a Kommerell diverticulum is the most common form of vascular ring. We report the outcomes of plication and pexy of the diverticulum in addition to division of the left-sided ligamentum to treat this lesion in children.MethodsForty-four patients were included in the study; 22 patients underwent division of the ligamentum arteriosum alone, while the other half underwent plication and/or pexy of the Kommerell diverticulum in addition to division of the ligamentum. The primary outcome of interest was reintervention for persistent symptoms following the initial operation. The other outcome studied was symptom relief on follow-up.ResultsThe baseline characteristics were similar between the two groups. There was no difference in the ratio of the size of the Kommerell diverticulum to the size of the left subclavian artery between the groups (1.6 vs 1.8, P = .22). The incidence of reoperation was similar in both groups (5% in each group, P = 1); 7/22 (32%) had persistent symptoms after ligamentum division alone, while only 1/22 (5%) had persistent symptoms after plication and/or pexy (P = .05).ConclusionPlication of the Kommerell diverticulum with pexy along with division of the ligamentum arteriosum is an effective alternative for treatment of right aortic arch with an aberrant left subclavian artery arising from the diverticulum.

Fenestrated/Branched Physician-Modified Endovascular Grafts for Aortic Pathologies Involving the Aberrant Subclavian Artery

PURPOSE

The case series aim to explore the feasibility and effectiveness of using fenestrated/branched physician-modified endovascular grafts (PMEGs) to treat aortic pathologies involving the aberrant subclavian artery (ASA).

TECHNIQUE

We presented 3 cases with multiple anomalies and complications related to the ASA. Two patients had aberrant right subclavian arteries (ARSA) and developed aortic dissection spontaneously or iatrogenically after endovascular intervention for myocardial infarction. The third patient had an aberrant left subclavian artery (ALSA) together with a Kommerell's diverticulum (KD) arising from a right-sided aortic arch and developed an aortic dissection. In all 3 cases, an Ankura thoracic endograft (Lifetech, Shenzhen, China) was back-table modified by adding an inner branch and a fenestration for bilateral subclavian arteries, respectively. All procedures were successfully conducted, and all patients underwent 6-month follow-up courses, which were uneventful.

CONCLUSION

Our case series demonstrate a feasible and less invasive therapeutic approach, which produces promising results in treating the aortic pathologies involving the ASA. Further studies and long-term follow-up are required to refine this technical approach and to validate its durability.

CLINICAL IMPACT

The case series illustrate a total endovascular approach to treat aortic arch pathologies involving the ASA, which is one of the most frequent aortic arch anomalies. The use of PMEGs allows meticulous subclavian artery reconstruction without significant trauma brought by traditional open or hybrid approach. Our cases suggest that using PMEGs for total endovascular management of patients with ASA is feasible and effective, and it may help streamline the treatment of complex aortic pathologies.

Midterm Outcome of Aortic Dissection Associated With Aberrant Subclavian Artery: A Single-Center Retrospective Observational Study

PURPOSE

The aberrant subclavian artery (aSA) is a rare anomaly of the aortic branches. Approximately 20-60% of patients with an aSA are associated with Kommerell's diverticulum (KD). These vascular anomalies have been reported to increase the risk of aortic rupture (4-19%) and aortic dissection. However, limited studies have investigated the treatment of aortic dissection in patients with aSA and KD. This study aims to investigate clinical characteristics and midterm follow-up outcomes of patients with aortic dissection associated with aSA.

MATERIALS AND METHODS

Between 2011 and 2021, a total of 48 patients with aSA anomalies underwent aortic dissection surgical intervention. Surgical interventions include open surgery, hybrid surgery, and endovascular therapy. Among them, 20 (41.7%) had Stanford type A dissection, 9 (18.8%) had Stanford type B dissection, and 19 (39.6%) had non-A non-B dissection. We report the early and midterm clinical outcomes including mortality, central nervous system complication and respiratory complication, and other operative outcomes including reintervention rates and endoleak. A subgroup analysis of the surgical and postoperative conditions was performed on Stanford type B and non-A non-B aortic dissection patients.

RESULTS

The mean age of the patient population was 48.81±9.65 years. The 30-day mortality rate was 12.5%. The overall mortality rate was 20.8%, with a median follow-up time of 4.5 years (interquartile range [IQR]: 2-8.75 years). Central nervous system complications occurred in 8 patients (16.7%), subclavian steal syndrome in 6 patients (12.5%), and respiratory complications in 3 patients (6.2%). The estimated Kaplan-Meier survival rates at 1 year, 3 years, 5 years, and 7 years after surgery were, respectively, 87.0%, 82.5%, 79.7%, and 75.1%. For Stanford type B and non-A non-B aortic dissection patients, the 30-day mortality rate between the open surgery group and the minimally invasive group had no statistically significant differences (18.3% vs 8.3%, p=0.815).

CONCLUSIONS

Surgical intervention for aSA patients with aortic dissection has poor outcomes. Early intervention might be considered for patients with aSA and KD to prevent the occurrence of aortic dissection.Clinical ImpactAberrant subclavian artery (aSA) and Kommerell's diverticulum (KD) have been reported to increase the risk of aortic rupture and aortic dissection. This study is currently the largest single-center retrospective study on aSA combined with aortic dissection, providing standardized data reporting and midterm follow-up of patients with this rare vascular anomaly.

Anatomic characteristics of the right aortic arch with aberrant left subclavian artery in patients who do and do not undergo vascular ring repair

INTRODUCTION

It is unclear if certain anatomic characteristics in patients with a right aortic arch with aberrant left subclavian artery (RAA ALSCA) are associated with undergoing surgical repair.

METHODS

This was a single-center retrospective study of patients with RAA ALSCA and computed tomography or cardiovascular magnetic resonance from July 2013-September 2023. The size of the proximal ALSCA or diverticulum of Kommerell (DoK), thoracic inlet index, angle of the proximal ALSCA/DoK from the aortic arch, the position of descending aorta, location of the DoK, and tracheal size were compared between patients who did or did not undergo surgery.

RESULTS

Of 163 patients meeting inclusion criteria, 56 ​% underwent surgery. Surgical patients had a larger indexed proximal ALSCA/DoK diameter and area, a higher indexed distance between the tip of the DoK and the opposite aortic wall, a greater proximal-to-distal LSCA ratio, a less acute angle of the proximal ALSCA/DoK from the aortic arch, a more leftward DoK location, and a lower thoracic inlet index compared to non-surgical patients. A larger indexed proximal ALSCA/DoK diameter, with an optimal threshold of ≥13.78 ​mm/m2, and a more leftward DoK location were independently associated with surgery. The reoperation rate was 11 ​%, and was associated with a less acute angle of the proximal ALSCA from the aortic arch.

CONCLUSIONS

A larger proximal ALSCA/DoK size and a more leftward DoK location were associated with surgical repair of RAA ALSCA, while a less acute angle of proximal ALSCA from the aortic arch was associated with reoperation.

Long-term Outcomes Following Thoracoscopic Division of Vascular Rings

OBJECTIVES

We evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center.

METHODS

All pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007-12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews.

RESULTS

60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time.

CONCLUSION

Division of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings.

LEVEL OF EVIDENCE

Level IV.

Outcomes of Patients Undergoing Surgery for Complete Vascular Rings

BACKGROUND

Few studies describe outcomes after complete vascular ring surgery in a comprehensive manner.

OBJECTIVES

This study sought to describe the clinical presentation, diagnostic work-up, operative approach, and outcomes in children undergoing surgery for complete vascular rings.

METHODS

This single-center retrospective cohort study includes consecutive patients (January 1990 through September 2023) undergoing primary surgery for complete vascular rings, or rerepair after primary surgery elsewhere. The primary outcome of interest was complete (as distinct from partial) symptom resolution at latest clinic follow-up. Our current preference is to pursue a comprehensive initial operation including adjunctive vascular and airway procedures targeting common causes of residual aerodigestive symptoms, such as Kommerell diverticulum resection and tracheobronchopexy. Preoperative work-up routinely involved computed tomographic angiography, dynamic bronchoscopy, and laryngoscopy.

RESULTS

Of 515 patients (including 39 rerepairs), the most common diagnoses were right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum (n = 323, 62.7%) and double aortic arch (n = 174, 33.8%). There was no perioperative mortality. Chylothorax occurred in 28 patients (5.4%), vocal cord dysfunction in 22 patients (4.3%), and diaphragm paralysis in 2 patients (0.4%). Follow-up was available on 453 patients (88.0%) with a median duration of 3.0 years (Q1-Q3: 0.6-9.2 years). At latest clinic follow-up, 429 patients (94.7%) reported complete symptom resolution. The risk of reoperation for residual or recurrent aerodigestive symptoms was 9.6% (95% CI: 5.7%-13.5%) at 10 years and 12.4% at 20 years (95% CI: 6.9%-17.8%).

CONCLUSIONS

Surgery for complete vascular rings provides good symptomatic relief with low risk of complications, whereas reoperations for aerodigestive symptoms are infrequent.

Upper partial sternal split for pediatric cardiac surgery

OBJECTIVES

We introduced the use of an upper partial sternal split for pediatric cardiac surgical procedures in our unit in 2016. We report the outcomes of our experience in 51 patients using this approach.

METHODS

From February 2016 to September 2022, 51 patients underwent congenital cardiac surgical procedures using an upper partial sternal split including vascular ring repair (n = 20), subaortic membrane (n = 12), ventricular septal defect closure with aortic valve resuspension (n = 9), aortic arch repair (n = 4), pulmonary artery band (n = 2), pulmonary artery sling (n = 1), supravalvular aortic stenosis (n = 1), aortic valve replacement (n = 1), and pulmonary artery plasty (n = 1). The surgical approach involved a midline skin incision, based on the manubrium, followed by an upper manubriotomy. No special surgical instrumentation was required. Median patient age was 2.9 years (IQR 1.3, 6.0); median body weight was 15 kg (IQR 9.8, 20).

RESULTS

There was no mortality and no patient required intraoperative conversion to full sternotomy. One patient required re-exploration for bleeding when the incision was converted to a full sternotomy. There were no wound complications in any patient. Twenty-one patients (41%) were extubated on the table and of the remaining 30 patients, 23 patients (76%) were extubated within 24 h of surgery. Eleven patients did not require intensive care unit (ICU) admission. Median ICU and hospital stay was 1 day (IQR 1, 1.25) and 5 days (IQR 4, 8) ,respectively.

CONCLUSION

An upper partial sternal split approach is straightforward and can be performed safely with a preferable cosmetic result in selected pediatric cardiac operations.

Outcomes of Surgical Repair of Aberrant Subclavian Arteries in Adults

BACKGROUND

Symptoms, imaging characteristics, and early and midterm surgical outcomes for aberrant subclavian arteries (ASCA) are not well defined in the adult population.

METHODS

A single-institution retrospective review was conducted of adults undergoing surgical repair of ASCA and descending aorta origin/Kommerell diverticulum (KD) from January 1, 2002, to December 31, 2021. Symptom improvement and differences in imaging characteristics between anatomic groups and the number of symptoms were assessed.

RESULTS

Mean age was 46 ± 17 years. There were 23 of 37 left aortic arches with right ASCA (62%) and 14 of 37 right aortic arches with left ASCA (38%). Of these, 31 of 37 (84%) were symptomatic, and 19 of 37 (51%) had KD size/growth meeting criteria for surgical repair. KD aortic origin diameter was larger in more symptomatic patients: 20.60 mm (interquartile range [IQR], 16.42-30.68 mm) in patients with ≥3 symptoms vs 22.05 mm (IQR, 17.52-24.21 mm) for 2 symptoms vs 13.72 mm (IQR, 12.70-15.95 mm) for 1 symptom (P = .018). Aortic replacement was required in 22 of 37 (59%). There were no early deaths. Complications occurred in 11 of 37 (30%): vocal cord dysfunction (4 of 37 [11%]), chylothorax (3 of 37 [8%]), Horner syndrome (2 of 37 [5%]), spinal deficit (2 of 37 [5%]), stroke (1 of 37 [3%]), and temporary dialysis requirement (1 of 37 [3%]). Over a median follow-up of 2.3 years (IQR, 0.8-3.9 years), there was 1 endovascular reintervention and no reoperations. Dysphagia and shortness of breath resolved in 92% and 89%, respectively, whereas gastroesophageal reflux persisted in 47%.

CONCLUSIONS

The KD aortic origin diameter correlates with the number of symptoms, and surgical repair of ASCA and descending aorta origin/KD effectively relieves symptoms, with low rates of reintervention. Given the operative complexity, surgical repair should be performed in patients meeting size criteria or with significant dysphagia or shortness of breath symptoms.

Post-operative Outcomes for Vascular Rings: A Systematic Review and Meta-analysis

OBJECTIVES

Vascular rings may cause tracheal and/or oesophageal compression. For many patients, symptoms/signs have been present for a long period before diagnosis. However, in the era of prenatal diagnosis, some units advocate universal early surgery. The risks and efficacy of surgery must be known to adequately counsel for the operation. This meta-analysis sought to define the morbidity and mortality associated with surgical correction, and persistent post-operative symptoms.

METHODS

PubMed, Cochrane Library and CINAHL databases were searched for studies that described the outcome of patients undergoing surgery for a double or right aortic arch (DAA or RAA). Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled rates of mortality, surgical complications, reintervention, and persistent follow-up symptoms.

RESULTS

Nineteen eligible studies were included comprising 18 studies describing outcomes for DAA surgery and 15 for RAA surgery. For DAA surgery, overall mortality rate was 0% [95% confidence interval (CI) 0.0-1.0], post-surgical complication rate 18% [95% CI: 12.0-23.0], prevalence of reintervention 3% [95% CI: 1.0-5.0] and prevalence of symptoms at last follow-up was 33% [95% CI: 17.0-52.0]. For RAA surgery, overall pooled mortality was 0% [95% CI: 0.0-0.0], prevalence of post-surgical complications was 15% [95% CI: 8.0-23.0], reintervention rate was 2% [95% CI: 0.0-4.0], prevalence of symptoms at last follow-up was 40% [95% CI: 26.0-55.0].

CONCLUSIONS

While surgery to correct a vascular ring is safe, the rate of persistent symptoms is high and further strategies must be sought to reduce this burden.

Management of prenatally detected vascular rings: a United Kingdom national survey

OBJECTIVE

To investigate UK variability in prenatal and postnatal management strategy of right aortic arch and double aortic arch (RAA/DAA).

METHODS

Online surveys were sent to senior physicians (consultants) of the National Fetal Cardiology Working Group regarding prenatal diagnosis, counselling, and perinatal management of antenatally diagnosed RAA/DAA and to the British Congenital Cardiovascular Association regarding postnatal management strategies.

RESULTS

There were 28 prenatal and 90 postnatal surveys completed. Prenatally, there was consensus for potential associated chromosomal/genetic anomalies, but there was variation in the risk quoted. Confidence in defining aortic arch morphology was reported by 43% (12/28) of fetal cardiologists. There was variation in what was felt to be possible symptoms/signs of a compressive vascular ring, postnatal investigation, postnatal management, follow-up duration of asymptomatic patients, and indications for surgical intervention.

CONCLUSION

This study has highlighted important areas for future research: improving accuracy of prenatal diagnosis, clarification of potential symptoms, optimal investigation strategies, and indications for surgery.

Rings and Slings: Not Such Simple Things

PURPOSE OF REVIEW

Vascular rings are congenital malformations resulting from abnormal development of the great vessels, with the consequent encircling and compression of the trachea, esophagus, or both. We conducted a review of the current literature to identify the different management strategies that can be implemented based on the prognosis of each of these anomalies.

RECENT FINDINGS

Although most vascular rings occur in isolation, they can also be associated with other congenital cardiac and/or respiratory diseases; therefore, thorough investigation is necessary before definitive surgical repair. Clinical presentation varies from asymptomatic to severe, with both respiratory and digestive symptoms. Although early surgical results are acceptable, the long-term outcome is variable; therefore, there is still controversy regarding the appropriate timing of treatment. This is especially true with regard to the Kommerell diverticulum (KD) and in patients without symptoms at the time of initial surgical evaluation. As more sophisticated diagnostic tools have become available and more studies on adults affected by this condition have been published, understanding of this condition and its additional clinical implications has grown and appears to be tilting management toward earlier intervention.

Concurrent double aortic arch and circumflex aorta repair in a symptomatic child: a case report

Double aortic arch with circumflex aorta is a rare type of vascular ring. Symptoms result from external compression of the trachea and esophagus. The best surgical approach for patients with double arch and circumflex aorta is debated, and options include the highly complex aortic uncrossing procedure. Herein we describe the surgical treatment of a patient with concurrent double aortic arch and circumflex aorta by division of the non-dominant arch and ligamentum arteriosum, plication and posterior tacking of the diverticulum of Kommerell. This left thoracotomy approach provided complete symptom resolution.

Contemporary surgical outcome and symptomatic relief following vascular ring surgery in children: effect of prenatal diagnosis

OBJECTIVES

Our goal was to describe postoperative complications and outcomes in a large contemporary cohort of children with an isolated double aortic arch (DAA) or a right aortic arch (RAA) with left arterial ligament and to assess the impact of foetal diagnosis on outcomes.

METHODS

We performed a retrospective analysis of all patients who underwent surgery for DAA or RAA with left arterial ligament between 2005 and 2019.

RESULTS

A total of 132 children were operated on for a DAA (n = 77) or a RAA (n = 55). Prenatal diagnosis was made in 100/132 (75.8%). Median age at surgery for DAA was 5.0 (1.7-13.3) months and for RAA was 13.9 (6.4-20.1) months. There was no difference in the age at surgery between the prenatal and postnatal cases (8.6 [4.0-15.6] vs 5.4 months [1.8-17.7]; P = 0.37). No surgical deaths occurred. Vocal cord palsy was the most common complication, occurring in 12/132 (9%): of these, 11 resolved spontaneously and 1 required a temporary tracheostomy. Logistic regression demonstrated that older age at operation was the only predictor for a postoperative complication (P = 0.02). Overall, 21/67 (31%) of prenatally detected, symptomatic cases reported residual symptoms/signs 1 year after surgery compared to 18/28 (64%) of postnatally detected cases. Postnatal diagnosis was associated with persistent postoperative symptoms/signs [P = 0.006, odds ratio = 3.9 (95% confidence interval 1.5-9.4)].

CONCLUSIONS

Surgery to relieve a vascular ring resolves trache-oesophageal compressive symptoms in most cases, but parents/patients should be aware that symptoms/signs may persist in the first postoperative year despite effective release of the vascular ring. Earlier surgery and prenatal diagnosis may improve outcomes.

Prenatal Diagnosis of Vascular Ring: Evaluation of Fetal Diagnosis and Postnatal Outcomes

BACKGROUND

The impact of fetal echocardiography on the diagnosis and outcomes of vascular ring has not been well examined. We hypothesized that prenatal detection of vascular ring has improved over time and that prenatal diagnosis of vascular ring is associated with earlier intervention and favorable outcomes.

METHODS

This is a single-center, retrospective study of the evolution and outcomes of prenatal diagnosis of vascular ring from 2000 to 2020. We compared clinical presentation, timing of surgical intervention, and outcomes between the prenatally and postnatally diagnosed cases during the same study period.

RESULTS

A total of 170 patients were included: 50 with prenatal and 120 with postnatal diagnosis of vascular ring. Prenatal diagnoses included 42 patients (84%) with right aortic arch (RAA), aberrant left subclavian artery (ALSCA), and a left-sided ductus arteriosus and eight (16%) patients with double aortic arch (DAA). The postnatal cohort consisted mainly of 90 patients (75%) with DAA and 22 (18%) with RAA-ALSCA. None of the postnatally diagnosed cases had undergone a fetal echocardiogram. Numbers (percentage) of prenatally diagnosed cases of vascular ring compared with the postnatal cases improved from 4/31 (13%), to 10/29 (34%), to 14/25 (56%), and to 22/35 (69%), respectively, during 2000-2005, 2005-10, 2010-15, and 2015-20 (P = .032). Vascular ring was an isolated abnormality in 84% and 85% of the prenatal and postnatal cohorts, respectively. Compared with the prenatal cohort, postnatally diagnosed patients with an isolated vascular ring were more frequently symptomatic (66% vs 48%, P < .03) and underwent cross-sectional imaging (69% vs 44%, P = .009) and surgery more frequently (79% vs 48%, P = .003). Surgery was performed at a later patient age (18 [2-147] months vs 4.8 [0.5-42] months, P = .01) and was more often associated with residual symptoms (27/81 [33%] vs 1/20 [5%], P = .01) in the postnatal cohort than in the prenatal cohort.

CONCLUSIONS

The diagnosis of vascular ring by fetal echocardiography has improved over time. A significantly higher incidence of RAA-ALSCA in the prenatal compared with the postnatal cohort suggests that patients with this form of vascular ring often do not present to medical attention with significant symptoms postnatally. Prenatal diagnosis of vascular ring was associated with a lower incidence of symptoms, less frequent use of cross-sectional imaging, earlier age at surgical intervention, and lower likelihood of residual symptoms.

Vascular rings

Vascular rings are congenital aortic arch anomalies that lead to compression of the trachea or esophagus. The goal of this review is to summarize our current recommendations for the management of patients with a diagnosis of a vascular ring. We review the history, classification methods, and epidemiology of the various types of vascular rings. We then propose a management strategy for the relatively new paradigm of fetal diagnosis, including the management of asymptomatic vascular rings. Finally, we finish with a review of the operative techniques and outcomes for the four main categories of vascular rings.

Mid-term results of vascular ring surgery

BACKGROUND

Vascular rings cause respiratory symptoms in children. Treatment consists of surgical division; however, data regarding mid-term results are scarce. The purpose of this study was to evaluate clinical results of vascular ring surgery.

METHODS

Retrospective chart review of consecutive patients who underwent vascular ring surgery. Mid-term follow-up consisted of clinic visits and telephone questionnaire over a 1-year period sampling at five points in time.

RESULTS

Follow-up of 85 patients who underwent vascular rings surgery revealed significant symptomatic improvement within 6 months. In total, 50% were symptomatic to some degree at their last documented clinic visit complaining of stridor (36.8%), cough (34.2%), wheezing (10.5%), dyspnoea on exertion (10.5%), or recurrent respiratory infections (23.7%). By telephone questionnaires, 83% described a significant improvement in respiratory symptoms, 63.4% had some residual symptoms, 36.6% stridor, 38.8% chronic cough, 32.4% bronchodilator use,18.3% had at least one episode of pneumonia per year, 31% of children had dyspnoea or respiratory limitation, and 12.7% while doing physical activities. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up.

CONCLUSIONS

Surgical division of vascular rings results in significant clinical improvement within 1 year; nevertheless, some patients remain symptomatic to some degree. We found no association between the age at surgery or anatomic variant to the presence of symptoms at mid-term follow-up. Further evaluation is warranted to assess the nature of residual symptoms and explore whether anatomical causes can be identified leading to surgical modifications.

Kommerell diverticulum, vascular ring, and aberrant left subclavian artery: LSCA translocation or aortopexy

BACKGROUND/PURPOSE

Kommerell diverticulum (KD) in children with right aortic arch and aberrant left subclavian artery can be treated surgically via left subclavian artery (LSCA) translocation or aortopexy. These procedures remain controversial. We compared the outcomes of both procedures.

METHODS

This retrospective study included 48 patients who underwent LSCA translocation (n = 26) or aortopexy (n = 22). Lateral thoracotomy and sternotomy were performed in 38 and 10 patients with severe intracardiac malformations, respectively.

RESULTS

The median age of the aortopexy group was 10 months, median follow-up was 14 months, and mean length of hospitalization was 11.41 ± 6.8 days. The median age of the LSCA translocation group was 12 months, median follow-up was 22 months, and mean length of hospitalization was 14.96 ± 7.74 days. Two patients (LSCA translocation group) required secondary intubations and none suffered from recurrent laryngeal nerve injury or complications related to LSCA translocation. Breathing and swallowing symptoms were relieved in all patients. No additional thoracotomies due to respiratory symptoms were required.

CONCLUSIONS

These two procedures relieve the pressure on the trachea and esophagus with similar short-term outcomes. The long-term outcomes are unknown. LSCA translocation may be the best strategy to prevent symptom recurrence and late complications in these patients.

LEVEL OF EVIDENCE

Level III.

Kommerell diverticulum: distinctions between arch side, and evaluation of morphology, size, and risk

BACKGROUND

Kommerell diverticulum (KD) is a dilated proximal aberrant subclavian artery associated with either right or left aortic arches (RAA-ARSA or LAA-ALSA). Although case series suggest KD may be a liability for vascular complications, the risk, pattern of dilation throughout the lifespan, and differences between arch sides, are not known.

METHODS

A single-center retrospective review of patients of all ages with KD on cross-sectional imaging. Maximal short axis diameter of KD (KDmax), absolute and indexed to descending aortic (DAo) diameter, was correlated with age. Comparisons were made between arch sides. Patients with vascular complications are described.

RESULTS

One hundred and four patients with KD were included [68 (65%) RAA-ALSA, 36 (35%) LAA-ARSA; 43 (41%) asymptomatic]. Although KDmax was correlated with age (RAA-ALSA r=0.84 [p<.0001]; LAA-ARSA r=0.51 [p=0.001]), KDmax/DAo was not (RAA-ALSA r=0.14 [p=0.27]; LAA-ARSA r=-0.22 [p=0.21]). RAA-ALSA had larger KDmax/DAo (1.02±0.20 vs 0.89±0.18 mm/mm, p=0.002), more symptoms (75% vs 28%, p <.0001), and younger age (median 9.5 vs 61.7 years, p<.0001). Six patients had vascular complications, age 58-80 years, all with LAA-ARSA and risk factors for acquired aneurysms.

CONCLUSIONS

In older patients, KDmax/DAo was not larger, arguing against isolated KD dilation with age. Diverticula from RAA-ALSA and LAA-ARSA demonstrate different phenotypes, suggesting different disease processes and likely different risk. The incidence of vascular complication was lower than previous reports, and occurred exclusively in patients with LAA-ARSA and aneurysm risk factors. This suggests conservative management of asymptomatic KD is often reasonable, especially with RAA-ALSA.

Translocation of aberrant left subclavian artery and resection of Kommerell diverticulum during the concomitant repair of intracardiac anomalies

OBJECTIVES

To assess the safety and efficacy of the translocation of the aberrant left subclavian artery (LSCA) and resection of the Kommerell diverticulum during the concomitant repair of intracardiac anomalies for paediatric patients who had a right-sided aortic arch.

METHODS

A retrospective review of paediatric patients who were diagnosed right-sided aortic arch, aberrant LSCA, Kommerell diverticulum and intracardiac anomalies between 2015 and 2019 was conducted. Patients who underwent translocation of the aberrant LSCA, diverticulum resection and concomitant intracardiac repair were included.

RESULTS

Eight patients underwent translocation of aberrant LSCA, diverticulum resection, ligamentum division and concomitant repair of the associated intracardiac anomalies. All patients were male. The median age was 1.3 years (range 0.4-5.5 years) and the median weight was 10.0 kg (range 6.1-21.0 kg). The most commonly combined intracardiac anomaly was a ventricular septal defect. Seven patients (87.5%) had preoperative respiratory or gastrointestinal symptoms. There was no early mortality and no postoperative complications. During the median follow-up of 23 months (range 4-43 months), no patient had residual respiratory or gastrointestinal symptoms. A postoperative computed tomography scan was performed in 3 patients, all of which showed patent LSCA-left carotid artery anastomosis.

CONCLUSIONS

Translocation of the aberrant LSCA and resection of the Kommerell diverticulum can be safely performed during the concomitant repair of intracardiac anomalies for paediatric patients. This approach could eliminate residual respiratory and gastrointestinal symptoms, and prevent reintervention in the future.

Right aortic arch forming a true vascular ring: a clinical review

OBJECTIVES

This review aims at presenting and summarizing the current state of literature on the presentation and surgical management of a right-sided aortic arch with a left-sided ligamentum forming a complete vascular ring around the oesophagus and trachea.

METHODS

A systematic database search for appropriate literature was conducted on PubMed/MEDLINE. Articles were considered relevant when providing details on the presentation, diagnosis and surgical treatment of this specific congenital arch anomaly in human beings.

RESULTS

Affected patients present with respiratory and/or oesophageal difficulties due to tracheoesophageal compression. Conservative treatment might be reasonable in asymptomatic or mildly symptomatic cases; however, once moderate-to-severe symptoms develop, surgical intervention is definitely indicated. Surgery is commonly performed through a left thoracotomy or median sternotomy and includes the division of the left ductal ligamentum; if a Kommerell's diverticulum is present that is >1.5 times the diameter of the subclavian artery, then concomitant resection of the large diverticulum and translocation of the aberrant left subclavian artery is also conducted. Postoperative morbidity and mortality are low and are rather related to concomitant intracardiac and extracardiac anomalies than to the procedure itself. In a majority of patients, full resolution of symptoms is seen within months to years from the surgery. Nevertheless, there is also a subset of patients who remain with some tracheobronchial narrowing, sometimes even requiring reintervention during follow-up due to persisting or recurring symptoms.

CONCLUSIONS

Overall, the surgical management of a right aortic arch forming a true vascular ring in infancy, childhood and adulthood seems relatively safe and effective in providing symptomatic relief despite some persistent tracheobronchial and/or oesophageal narrowing in some cases.

Ultrastructural Features of the Aortic Wall in a Patient with Kommerell Diverticulum

We report on the ultrastructural features of the aortic wall in a patient with Kommerell diverticulum. A 70-year-old woman with a right aortic arch, aberrant left subclavian artery, and Kommerell diverticulum underwent a successful total arch replacement plus the frozen elephant trunk procedure with anatomical left subclavian artery reconstruction. Small pieces of the ascending aorta, distal arch, right common carotid artery, and left subclavian artery were investigated ultrastructurally. In the ascending aortic wall, multiple cystic cavities were observed in the subintimal region of the media by scanning electron microscopy. Changes in organelles, including mild dilation of rough-surfaced endoplasmic reticulum and mitochondrial swelling and degrading, were also observed in all specimens by transmission electron microscopy. These ultrastructural features may indicate the fragility or stress of the aortic wall and are useful when considering the early surgical intervention of a patient with Kommerell diverticulum.

Influence of Fetal Diagnosis on Management of Vascular Rings

BACKGROUND

There has been an increasing frequency of fetal diagnosis of vascular rings. We compared management strategies and outcomes of infants with fetal diagnosis to those with postnatal diagnosis to inform recommendations regarding optimal management.

METHODS

Retrospective review was performed of vascular ring operations from 1/2000 to 6/2019. Standard demographic data (preoperative clinical status, timing of diagnosis, cross-sectional imaging, operative and perioperative details, and clinical outcomes) were collected. Statistical analysis was performed to compare characteristics and outcomes of fetal versus postnatal diagnosis.

RESULTS

There were 190 patients, with 15% (n=29) diagnosed prenatally. Anatomic variants were: double aortic arch (n=66, 14 fetal diagnosis), right aortic arch, aberrant left subclavian artery (n=94, 12 fetal diagnosis), circumflex aorta (n=7, 1 fetal diagnosis), and pulmonary artery sling (n=19, 2 fetal diagnoses). Increasing frequency of fetal diagnosis was noted in the past 10 years. In 2012 1/9 (11%) patients had a fetal diagnosis, in 2018 8/11 (72%) had a fetal diagnosis (p<0.001). Patients with a fetal diagnosis were significantly younger at the time of surgery (13.1 months [20.6] vs. 24.0 months [87.0], p=0.029). There was no difference in postoperative complications or length-of-stay (3 days [1] for fetal diagnosis vs. 4 days [3] for postnatal diagnosis, p=0.50).

CONCLUSIONS

Fetal diagnosis leads to the potential for expectant management of vascular ring patients. This has resulted in earlier time of intervention with no increase in postoperative morbidity. This may lead to improved long-term outcomes and potentially alter the natural history for these children.

Frozen Elephant Trunk to Exclude the Kommerell Diverticulum Associated with Double Aortic Arch in Adult Redo Patient

Kommerell diverticulum can be associated to several types of vascular rings, including double aortic arch. Surgical indications for vascular rings and Kommerell diverticulum include bulging symptoms onto trachea and esophagus too. Moreover, the aneurysmal enlargement over time can eventually cause acute aortic syndromes. Management of this pathology in adulthood is challenging and many techniques have been proposed, notably hybrid solutions. Herein, we report the case of a patient, who underwent redo surgery with frozen elephant trunk technique, caused by persisting symptoms after a previous operation of vascular ring interruption.

Surgical Outcomes of Kommerell Diverticulum

Background

We aimed to assess the clinical outcomes of patients who underwent surgical repair of Kommerell diverticulum (KD) with individualized surgical methods.

Methods

A retrospective analysis was performed of adult patients (aged ≥17 years) who underwent surgery to treat KD between June 2008 and October 2019.

Results

Nine patients (median age, 45 years; range, 19–67 years; 7 men) underwent surgical repair. The indications for surgical therapy were acute aortic dissection in 2 patients, the presence of compressive symptoms due to dilated KD in 4 patients, and aneurysm growth in 3 patients. Various surgical techniques were used (1) resection of the diverticulum stump and revascularization of the aberrant subclavian artery (n=3), (2) one-stage total-arch replacement including the diverticulum segment (n=3), and (3) hybrid repair (n=3). Early mortality occurred in 1 case of hybrid repair. Transient paraparesis occurred in a patient who underwent total arch repair as part of complicated acute aortic dissection. During follow-up (median duration, 30 months; range, 7–130 months), no late death or associated aortic complications were documented. All survivors were free from symptoms and had no abnormal findings on follow-up computed tomography.

Conclusion

With a customized surgical approach and appropriate consideration of patient-specific anatomy and associated comorbidities, KD can be repaired with favorable outcomes.

Safety and efficacy of a hybrid approach for repair of complicated aberrant subclavian arteries

OBJECTIVE

Aberrant subclavian artery (ASA), a well-described aortic arch anomaly, is frequently associated with dysphagia and development of Kommerell diverticulum (KD) with aneurysmal degeneration. Historically, open repair has been performed, which can be associated with significant morbidity. More recently, hybrid approaches using different arch vessel revascularization techniques in combination with thoracic endovascular aortic repair (hybrid TEVAR) have been described, but there is a paucity of literature describing outcomes. The objective of this analysis was to describe our experience with management of complicated ASAs using hybrid TEVAR, further adding to the literature describing approaches to and outcomes of hybrid ASA repair.

METHODS

A retrospective, single-institution review was performed of all patients treated for ASA complications using hybrid TEVAR (2002-2018). The primary end point was technical success, defined as absence of type I or type III endoleak intraoperatively and within 30 days postoperatively. Secondary end points included complications, reintervention, and survival. Centerline measurement of KD diameters (maximum diameter = opposing aortic outer wall to diverticulum apex) was employed. Kaplan-Meier methodology was used to estimate secondary end points.

RESULTS

Eighteen patients (1.4% of 1240 total TEVAR procedures; male, 67%; age, 59 ± 13 years) were identified (left-sided arch and right ASA, 94% [n = 17]; right-sided arch and left ASA, n = 1 [6%]; retroesophageal location and associated KD, 100%); median preoperative KD diameter was 60 mm (interquartile range [IQR], 37-108 mm). Operative indications included diverticulum diameter (61%), dysphagia (17%), rupture (11%), rapid expansion (6%), and endoleak after TEVAR (6%). All procedures used some combination of supraclavicular revascularization and TEVAR (staged, 50% [n = 9]), whereas partial open arch reconstruction was used in 17% (n = 3). There were no perioperative deaths or spinal cord ischemic events. Major complications occurred in 22% (n = 4): nondisabling stroke, one; arm ischemia, one; upper extremity neuropathy, one; and iatrogenic descending thoracic aortic dissection, one. Technical success was 83%, but 44% (n = 8) had an endoleak (type I, n = 3; type II, n = 5 [intercostal, n = 2; aneurysmal subclavian artery origin, n = 3]) during follow-up (median, 4 months; IQR, 1-15 months). Two endoleaks resolved spontaneously, three were treated, and three were observed (1-year freedom from reintervention, 75% ± 10%). Median KD diameter decreased by 7 mm (IQR, 1-12 mm), and 78% (n = 14) experienced diameter reduction or stability in follow-up. The 1- and 3-year survival was 93% ± 6% and 84% ± 10%, respectively.

CONCLUSIONS

Hybrid open brachiocephalic artery revascularization with TEVAR appears to be safe and reasonably effective in management of ASA complications as evidenced by a low perioperative complication risk and reasonable positive aortic remodeling. However, endoleak rates raise significant concerns about durability. Therefore, if this technique is employed, the mandatory need for surveillance and high rate of reintervention should be emphasized preoperatively. This analysis represents a relatively large series of a hybrid TEVAR technique to treat ASA complications, but greater patient numbers and longer follow-up are needed to further establish the role of this procedure.

Supraclavicular Translocation of Aberrant Left Subclavian Artery for Vascular Ring Division and Resection of Kommerell’s Diverticulum

Intrathoracic left subclavian to common carotid artery translocation is advocated for patients undergoing vascular ring division in the setting of an enlarged Kommerell’s diverticulum and aberrant left subclavian artery. This approach poses technical challenges in larger patients and patients with unfavorable body habitus. Supraclavicular left subclavian artery to common carotid translocation greatly simplifies this procedure in select patients.

Resection of Kommerell's diverticulum in an infant with prenatal diagnosis of right aortic arch

BACKGROUND

A right aortic arch is a congenital vascular anomaly that is present in up to 0.1% of pregnancies. The anomaly observed by fetal ultrasonography was recently reported to indicate vascular and chromosomal abnormalities that may complicate postnatal management.

CASE PRESENTATION

We report the successful resection of a Kommerell's diverticulum with left subclavian artery transfer to the left carotid artery in a 5-month-old Japanese boy. The patient was prenatally diagnosed as having a right aortic arch, and a vascular ring was confirmed at 4 months of age with enhanced computed tomography. The pathology of the resected aortic wall revealed severe disruption and fragmentation of elastic fibers associated with a disarray of smooth muscle cells in the tunica media, and cystic medial necrosis with mucoid extracellular matrix deposition.

CONCLUSION

These abnormal pathological findings supported the resection of Kommerell's diverticulum at this point of time, and division of the ligamentum arteriosus alone was not recommended. Early intervention in this condition once the diagnosis is made may thus be advocated. The fetal diagnosis of a right aortic arch may provide a clue to the possibility of a vascular ring.

Cerebral regional oxygen saturation: a useful monitor during a surgical procedure involving the right-sided aortic arch in an infant

A right aortic arch with an aberrant left subclavian artery and a Kommerell's diverticulum represents a rare anatomic variant carrying the risk of dissection or rupture. Resection of the diverticulum and re-implantation of the left subclavian artery during childhood have been recommended. Because of the risk of cerebral blood flow reduction during the aberrant subclavian artery re-implantation to the common carotid artery, monitoring and prompt measures to curb blood flow reduction are required. A 5-month-old boy was scheduled to undergo resection surgery. During the translocation of the aberrant subclavian artery to the common carotid artery, his regional oxygen saturation (rSO₂) in the left cerebrum began to decrease. We increased the end-tidal CO₂ (EtCO₂), mean arterial pressure, and a fraction of inspired oxygen, successfully restoring the rSO₂ to the initial level. No postoperative neurological complications were observed. Our experience with this patient suggests that rSO₂ monitoring is a useful, and intervention protocol including hypercapnia, elevated mean arterial pressure, and hyperoxia to counter the decreased cerebral blood flow is effective in infant patients undergoing right-sided aortic arch surgery.

ATTEMPTED SURGICAL CORRECTION OF A PERSISTENT RIGHT FOURTH AORTIC ARCH IN A JUVENILE ROTHSCHILD'S GIRAFFE (GIRAFFA CAMELOPARDALIS ROTHSCHILDI)

A 5-mo-old female Rothschild's giraffe ( Giraffa camelopardalis rothschildi) presented for regurgitation. Esophagoscopy at 24 wk of age revealed a markedly dilated cranial esophagus with a tight stricture at the level of the heart base consistent with a vascular ring anomaly. Surgical exploration confirmed persistent right fourth aortic arch with ductus originating from left subclavian artery at its junction with the aorta and left subclavian artery. The patent ductus arteriosus was surgically ligated. The procedure was complicated by limited surgical access and vascular friability resulting in uncontrollable hemorrhage, and the animal was euthanatized. The animal's large size and unique shape precluded preoperative examination by computed tomography. Surgical accessibility was poor because cranial retraction of the thoracic limb was limited. Histology revealed focal degeneration of the aorta and subclavian artery and muscular degeneration of the esophagus. Degeneration was attributed to local hypoxia from compression by the vascular structure as the animal grew.

Saccular Kommerell aneurysm, a potential pitfall on MDCT imaging - A review of imaging features and potential mimics

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Kommerell aneurysm is an outpouching from a kommerell diverticulum.

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Mimics include saccular aneurysm of the thoracic aorta, ductus diverticulum and dilated Kommerell diverticulum.

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Kommerell aneurysm has the tendency to rupture, therefore, accurate diagnosis is critical.

Saccular Kommerell aneurysm represents a potential pitfall on Multidetector CT (MDCT) imaging, mimicking conditions such as saccular aneurysm of the thoracic aorta, ductus diverticulum and dilated Kommerell diverticulum. Accurate diagnosis of this condition is critical in the management of this potentially fatal condition. This paper reviews the MDCT imaging features of Kommerell aneurysms and its mimics and demonstrates how to make an accurate diagnosis through a series of four cases. MDCT features of Kommerell aneurysms, either saccular or fusiform types arising from a Kommerell diverticulum with atherosclerotic plaque and mural thrombus are discussed.

Modified Norwood Procedure for Tricuspid Atresia, Transposition of Great Arteries, and Hypoplastic Right Arch With Complete Vascular Ring

We report a modified Norwood stage I procedure for tricuspid atresia, transposition of great arteries, and hypoplastic right aortic arch with complete vascular ring. In this technique, we applied dual arterial cannulation to avoid circulation arrest during neoaortic reconstruction, and also corrected the arch laterality during the Norwood stage I palliation procedure. Pulmonary flow was supplied by the Blalock-Taussig shunt. Postoperative imaging revealed the patent left neoaortic arch, and the vascular ring was relieved with a patent tracheobronchial tree.

Multidetector Computed Tomography for Congenital Anomalies of the Aortic Arch: Vascular Rings

The development of multidetector computed tomography has triggered a revolution in the study of the aorta and other large vessels and has replaced angiography in the diagnosis of congenital anomalies of the aortic arch, particularly vascular rings. The major advantage of multidetector computed tomography is that it permits clear 3-dimensional assessment of not only vascular structures, but also airway and esophageal compression. The current update aims to summarize the embryonic development of the aortic arch and the developmental anomalies leading to vascular ring formation and to discuss the current diagnostic and therapeutic role of multidetector computed tomography in this field.

Vascular rings

The term vascular ring refers to congenital vascular anomalies of the aortic arch system that compress the esophagus and trachea, causing symptoms related to those two structures. The most common vascular rings are double aortic arch and right aortic arch with left ligamentum. Pulmonary artery sling is rare and these patients need to be carefully evaluated for frequently associated tracheal stenosis. Another cause of tracheal compression occurring only in infants is the innominate artery compression syndrome. In the current era, the diagnosis of a vascular ring is best established by CT imaging that can accurately delineate the anatomy of the vascular ring and associated tracheal pathology. For patients with a right aortic arch there recently has been an increased recognition of a structure called a Kommerell diverticulum which may require resection and transfer of the left subclavian artery to the left carotid artery. A very rare vascular ring is the circumflex aorta that is now treated with the aortic uncrossing operation. Patients with vascular rings should all have an echocardiogram because of the incidence of associated congenital heart disease. We also recommend bronchoscopy to assess for additional tracheal pathology and provide an assessment of the degree of tracheomalacia and bronchomalacia. The outcomes of surgical intervention are excellent and most patients have complete resolution of symptoms over a period of time.