Aneurysm of a right-sided aortic arch and right descending aorta: Three-dimensional volume rendering of multislice computed tomographic aortography facilitates surgical planning and management

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 repair of intrathoracic ruptured Kommerell’s diverticulum

A right-sided aortic arch associated with an aberrant subclavian artery is a rare anomaly. Regardless, this condition is clinically relevant because mortality is associated with rupture, morbidity results from compression of mediastinal structures, and the surgery is complex. We describe the successful surgical repair of this vascular anomaly by totally debranching the neck vessels and placing an endovascular stent-graft to exclude the ruptured Kommerell’s diverticulum.

Aneurysm of a right-sided descending thoracic aorta with a left-sided aortic arch and aberrant right subclavian artery

We describe a rare case of an arteriosclerotic aneurysm in the right-sided descending thoracic aorta with a left-sided aortic arch and concomitant aberrant right subclavian artery. A 76-year-old woman, who was found to have an aneurysm of the right-sided descending thoracic aorta, was referred to our hospital for surgical treatment. Contrast computed tomography scan revealed a left-sided aortic arch with an aberrant right subclavian artery, a descending thoracic aorta passing downward behind the esophagus, and an aneurysm of the right-sided and distal (level between the 8th and 10th vertebral bodies) descending thoracic aorta. With a right posterolateral thoracotomy, the patient underwent descending thoracic aorta replacement using an 18-mm woven Dacron prosthesis. The patient had an uneventful postoperative course and was discharged 24 days after surgery. Histological microscopic examination of the resected aneurysmal wall revealed an arteriosclerotic aneurysm. The postoperative computed tomography scan 18 days after surgery revealed no anastomotic aneurysm or abnormal fluid collection.

Clamshell approach and partial cardiopulmonary bypass to repair a right aortic arch aneurysm

AB A 27-year-old man with history of ventricular septal defect repair in infancy presented with aneurysm of Edwards type IIIB right aortic arch. Karyotype analysis excluded chromosome 22 anomalies. The lesion was repaired using beating heart partial cardiopulmonary bypass via a clamshell incision. Postoperative course was uneventful.