Two cases of thoracic aortic aneurysm with right aortic arch: comparison of two operative strategies for hybrid thoracic endovascular repair

Midterm Morphological Change of Kommerell's Diverticulum after Hybrid Thoracic Endovascular Aortic Repair

BACKGROUND

Kommerell's diverticulum (KD) is associated with a high incidence of right-sided aortic arch (RAA). Hybrid thoracic endovascular aortic repair (TEVAR) is an effective and less invasive alternative to open repair. However, the long-term results regarding KD diameter regression or symptom improvement remain inadequately described.

METHODS

Nine patients underwent TEVAR for KD associated with RAA between January 2016 and September 2023 at our university hospital and affiliated institutions. A hybrid procedure was performed to exclude KD by blocking the proximal blood flow with TEVAR and distal blood flow with embolization of the aberrant subclavian artery. Simultaneously, extra-anatomical bypass surgery was performed to revascularize the covered supraarch vessels.

RESULTS

The patients' mean age was 65.2 years, and 6 patients were men. Two patients presented with dysphagia, whereas the rest were asymptomatic. The mean diameter and distance to the opposite aortic wall (OAW) of KD were 32.1 mm and 56.2 mm, respectively. For revascularization of the covered supraarch vessels, 6 and 2 patients underwent total debranching with sternotomy and extra-thoracic bypass (bilateral common carotid artery-axial artery bypass), respectively. The 30-day and in-hospital mortality rates were 0%, with no instances of cerebral infarction or spinal cord ischemia. The mean follow-up period was 3.2 years. The survival and avoidance rates of aortic events were 100% at 1 and 3 years. Follow-up computed tomography scans showed no endoleaks; however, 1 (11.1%) type 2 endoleak from the aberrant left subclavian artery occurred 1 week postoperatively, necessitating additional coiling. Seven patients were followed up for more than 1 year, with 5 experiencing reductions of more than 3 mm in KD diameter, distance to the OAW, or both.

CONCLUSIONS

Although further follow-up and investigations are needed, TEVAR may be a safe and effective surgical treatment for KD associated with RAA.

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.