Kommerell's diverticulum in the current era: a comprehensive review

Three Rare Structural Anomalies: Right Aberrant Subclavian Artery, Kommerell's Diverticulum, and Isolated Left Vertebral Artery All Associated with Type B Aortic Dissection

Introduction and Background

Right aberrant subclavian artery accounts for 0.5-1.8% of the population as the most frequently encountered aortic arch anomaly, while the prevalence of an isolated left vertebral artery ranges from 3 to 8%. Despite the low prevalence and the asymptomatic presentation of these structural anomalies, the development of cardiovascular complications and aneurysmal formation could happen as in Kommerell's diverticulum in a complicated right aberrant subclavian artery, which can undergo aneurysmal degeneration and dissection. Depending on the severity and the degree of the symptoms, the management of the patient can be determined.

Case Presentation

A 51-year-old male hypertensive Pakistani patient was admitted complaining of chest and back pain; a CT of the aorta was done and showed type B aortic dissection associated with a right aberrant subclavian artery with an isolated left vertebral artery. A thoracic endovascular aneurysmal repair was done, and the patient improved afterward.

Conclusion

The prevalence of these structural anomalies, the right aberrant subclavian artery, Kommerell's diverticulum, and isolated left vertebral artery with type B aortic dissection, is uncommon. Therefore, the earlier the diagnosis, the better the treatment. This is the first case report explaining the occurrence of these vascular anomalies together in Saudi Arabia.

Aberrant right subclavian artery (arteria lusoria) aneurysm with a Kommerell's diverticulum

The treatment options for aberrant right subclavian artery vary depending on the presence of Kommerell’s diverticulum. Because there is a tendency not to report mortalities of these rare cases in the literature, it is hard to reach a conclusion on treatments from the limited data on post-interventional results in these patients. We report our experience with a 67-year old patient with an aberrant right subclavian aneurysm with Kommerell’s diverticulum, diagnosed by chance.

Kommerell Diverticulum: Right Aortic Arch with Anomalous Origin of Left Subclavian Artery and Duplicity of Right Vertebral Artery in a 16-Year-Old Girl

Patient: Female, 16

Final Diagnosis: Kommerell diverticulum

Symptoms: Tachycardia

Medication: —

Clinical Procedure: Clinical observation only

Specialty: Cardiology

Distal Limited Open Stenting for Aortic Diverticulum in the Right Aortic Arch

An aortic diverticulum, including Kommerell's diverticulum, is an uncommon, congenital, aortic arch anomaly. Surgery for a diverticulum is challenging, and several surgical strategies have been reported. Here, we present the case of an asymptomatic 57-year-old man who was referred to our hospital. Computed tomography revealed right aortic arch and aortic diverticulum, and he underwent distal limited open stenting under hypothermic circulatory arrest with selective cerebral perfusion via median sternotomy. The postoperative course was uneventful. Thus, this report shows that our procedure is useful and safe for treating aortic diverticulum.

Anatomical variations of aortic arch vessels in Japanese patients with aortic arch disease

OBJECTIVES

The present study analyzed the prevalence of variations of the aortic arch branching in Japanese population, comparing patients with aortic arch disease with healthy controls.

METHODS

Between from October 1999 and December 2015, 815 Japanese patients with aortic arch disease defined as aortic arch aneurysm (diameter ≥ 45 mm) and aortic dissection (group A) underwent aortic arch surgery in our institution. As a control group, 1506 traumatic screened patients were enrolled (group C).

RESULTS

Aortic arch anomaly was diagnosed in 140 patients (17.2%) in the group A and in 222 patients (14.7%) in the group C (p = 0.125). Significant differences were found in the incidence of aberrant subclavian artery (A: 14 patients, 1.7%, vs. C: 8 patients, 0.5%, p = 0.006). Significantly more patients with aortic arch aneurysm in the group A had anomalies of the aortic arch compared with the group C (p = 0.009), including bovine aortic arch (p = 0.049) and aberrant subclavian artery (p < 0.001). In term of aneurysm location, bovine arch was detected in more patients with proximal arch aneurysm (15.7%, p = 0.043), whereas aberrant subclavian artery was in more patients with distal location (3.7%, p < 0.001). No difference was found in aortic arch anomaly in patients with acute or chronic dissection.

CONCLUSION

Aberrant subclavian artery was a significant maker of aortic arch disease in Japanese populations. Bovine arch was a risk maker of proximal arch aneurysm, and aberrant subclavian artery was a risk factor of distal arch aneurysm.

Mid-term follow-up study of neonatal isolated aberrant right subclavian artery

BACKGROUND

Aberrant right subclavian artery is the most common congenital aortic arch anomaly. There are a few reports concerning the clinical manifestations and follow-up of this CHD detected by echocardiographic screening.

METHODS

A total of 1737 full-term neonates, with a male-to-female ratio of 900:837, received echocardiographic screening. Neonates with or without isolated aberrant right subclavian artery were studied during infancy.

RESULTS

Among the 1737 cases, a total of 15 (0.86%) female-predominant neonates, with a male-to-female ratio of 6:9, had isolated aberrant right subclavian artery. They were compared with 20 age- and gender-matched normal neonates. There were no significant differences in maternal age, gestational age, or para gravity between the two groups, except for birth size (birth length- and weight-for-age percentiles, p = 0.006 and 0.045, respectively), which was smaller in the aberrant right subclavian artery group. Although there were no significant differences in developmental history, gastrointestinal, or respiratory symptoms, neonates with aberrant right subclavian artery had a higher incidence of mild developmental delay and feeding difficulty than normal infants (21 versus 0%, p = 0.061; 36 versus 20%, p = 0.264, respectively). The growth rates of body length and weight during infancy were not significantly different between the two groups.

CONCLUSIONS

Echocardiography can be applied as a first-line investigation in the diagnostic work-up for aberrant right subclavian artery. Neonates with aberrant right subclavian artery had a smaller size at birth, although growth rates were not significantly different from those of normal infants. This study does not support an active surgical policy for asymptomatic infants with isolated aberrant right subclavian artery. A larger study and longer follow-up of affected infants is recommended.

Severe oesophageal constriction due to an aberrant right subclavian artery with Kommerell's diverticulum in a cat

Case summary

A 6-month-old female cat with a history of chronic regurgitation presented with weight loss. CT angiography (CTA) showed severe constriction of the oesophagus due to an aberrant right subclavian artery and Kommerell’s diverticulum. The cat was surgically treated and remained clinically normal. More than 1 year after surgery, the general condition of the cat was stable and body weight had increased.

Relevance and novel information

This case report describes the clinical findings and surgical management of a cat diagnosed with severe oesophageal constriction caused by an aberrant right subclavian artery with Kommerell’s diverticulum (markedly dilated origin of the aberrant right subclavian artery), which are rare vascular anomalies in veterinary medicine and specifically in cats. The Kommerell’s diverticulum compressed the oesophagus and contributed to the severe oesophageal constriction in this case. Preoperative CTA was useful in the diagnosis and treatment planning.

Migration of endovascular plug in hybrid repair of dysphagia lusoria

Aberrant right subclavian artery is the most common brachiocephalic artery congenital abnormality and may result in dysphagia from external compression by the aberrant artery on the esophagus. Repair of this anatomic variant can be performed by both open and hybrid endovascular techniques. This case illustrates a complication of a hybrid repair resulting in proximal migration of a vascular occlusion plug, presenting as recurrent dysphagia and need for open surgical extraction of the plug.

A case report of frozen elephant trunk combined with endovascular treatment for acute aortic dissection of Kommerell's diverticulum involving right aortic arch and descending aorta

RATIONALE

Acute aortic dissection of Kommerell's diverticulum in the right aortic arch is extremely rare. There are several different procedures for the disease. With advances in endovascular treatment, hybrid surgical and endovascular management may provide a treatment of choice for this kind of disease.

PATIENT CONCERNS

A 43-year-old man was admitted to the hospital with intermittent pain of left arm, chest, and back.

DIAGNOSES

Computed tomography demonstrated an aberrant left subclavian artery originating from Kommerell's diverticulum in the right aortic arch, acute aortic dissection of Kommerell's diverticulum involving arch and descending aorta.

INTERVENTIONS

Total arch replacement combined with frozen elephant trunk was performed to create an adequate landing zone through a median sternotomy by circulatory arrest. Thoracic endovascular aortic repair was performed to isolate Kommerell's diverticulum from descending aorta completely, extending from the frozen elephant trunk to the distal descending aorta at the same time.

OUTCOMES

The patient got an uneventful postoperative course.

LESSONS

Hybrid surgical and endovascular management is a safe and effective procedure for this rare disease.

Patient-specific three-dimensional printing for Kommerell's diverticulum

BACKGROUND

Kommerell's diverticulum is a complex congenital malformation of aorta. Three-dimensional (3D) printing is an innovative manufacturing process that allows computer-assisted conversion of 3D imaging data into physical "printouts." The aim of this study was to explore the feasibility and impact of using patient-specific 3D-printed cardiac prototypes derived from computed tomography data on surgical decision-making and preoperative planning for Kommerell's diverticulum.

METHODS

From April to August 2017, five patients with Kommerell's diverticulum were diagnosed and chosen for study. Cardiac computed tomography was done for all patients. One case was diagnosed with left aortic arch, and another four cases presented right-sided aortic arch and aberrant left subclavian artery. In addition, one patient complicated with aortic dissection. Data were used to generate patient-specific 3D models. All cases were reviewed along with their models, and the impact on surgical decision-making and preoperative planning was assessed.

RESULTS

Accurate life-sized 3D models were successfully printed for all patients. These models enabled improved understanding of aortic malformation and preoperative planning. 3D models also allowed real-time intraoperative guidance for surgeons.

CONCLUSIONS

3D printed models can improve the understanding of anatomy and allow anticipation of surgical technique challenges, which could radically assist surgical planning, and safe execution of surgery for Kommerell's diverticulum. The combination of 3D printing technique and surgical procedure is a promising perspective for treatment of complex aortic malformation.

Incidental finding of arteria lusoria during transradial coronary catheterization: Significance in interventional cardiology

Arteria lusoria is the most common anomaly of the aortic arch with an incidence of 0.5%-2.5%. It is mostly diagnosed incidentally while performing imaging for evaluation of other unrelated medical conditions. The aberrant right subclavian artery arises beyond the origin of the left subclavian artery from the aortic arch. This results in a complex right-subclavian-aortic anatomy which leads to difficulty in transradial coronary angiography. This can lead to prolonged procedure time and increased use of catheters by unaware interventionists. This is even more important if this is encountered in the setting of an acute myocardial infarction. Our review takes into account clinical significance of this uncommon anomaly in the field of interventional cardiology.

Successful Prediction of a Left Nonrecurrent Laryngeal Nerve in a Patient With Right-Sided Aorta and Aberrant Left Subclavian Artery

BACKGROUND

Left nonrecurrent laryngeal nerve (LNRLN) is an extremely rare anatomic variant. The development of such anatomic variation requires the regression of both the fourth (aortic arch) and sixth (ductus arteriosus, DA) arches on the left side. Preoperative prediction of this variant is difficult but might reduce risk of nerve injury.

METHODS

A 34-year-old female was indicated for thyroidectomy for a 2.4 cm follicular neoplasm and Graves' disease. Due to a positive medical history of 22q11.2 microdeletion and unexplained left vocal cord paralysis, a preoperative chest computed tomography (CT) scan was obtained and revealed a right-sided aorta (RSA) and aberrant left subclavian artery (ALSA) without Kommerell's diverticulum. A left-sided NRLN was then highly suspected.

RESULTS

Thyroidectomy was performed under general anesthesia with the utilization of intraoperative laryngeal nerve monitoring. A LNRLN was confirmed intraoperatively.

CONCLUSIONS

Right-sided aorta and ALSA indicate embryologic regression of the left fourth primitive aortic arch. The absence of Kommerell's diverticulum at the origin of the ALSA indicates the lack of high-pressure blood flow from the pulmonary artery to the ALSA through the ductus arteriosus during embryogenesis, suggesting the embryologic regression of the left sixth primitive aortic arch. The presence of all 3 radiologic features thus highly suggests the possibility of a LNRLN.

Wheezing and dyspnoea caused by aberrant left innominate artery

We present a rare case of a branching anomaly of the aortic arch that resulted in wheezing and dyspnoea. The patient was a 60‐year‐old male with severe wheezing from babyhood, originally diagnosed with severe bronchial asthma. On auscultation, the inspiratory and expiratory wheezes appeared when the patient leaned forward. He also had difficulty in swallowing solid mass. Tests for airway reversibility and hyperresponsiveness were negative, and asthma treatment was ineffective. He had a right aortic arch. A barium oesophagogram and endoscopic examination indicated narrowing of the oesophagus from behind. Three‐dimensional reconstruction of enhanced chest CT images indicated a right aortic arch and an aberrant enlarged left innominate artery, which compressed and narrowed the oesophagus and trachea from behind. Although the patient had been diagnosed with intractable bronchial asthma, his symptoms were more likely caused by this mechanical narrowing as wheezing and dyspnoea disappeared completely after total aortic arch replacement operation.

Hybrid Endovascular Repair of a Right-Sided Thoracoabdominal Aortic Aneurysm

A right-sided thoracoabdominal aortic aneurysm involving a right-sided aortic arch is extremely rare. Surgical treatment for a right-sided thoracoabdominal aortic aneurysm is challenging due to the anatomical complexity. We report a case of a right-sided thoracoabdominal aortic aneurysm with a right-sided aortic arch successfully treated by hybrid visceral debranching and endovascular repair.

Total arch replacement through a median sternotomy for Kommerell's diverticulum

Kommerell's diverticulum with a right aortic arch and aberrant left subclavian artery is a rare anomaly, and the optimal operative strategy has not yet been established. In particular, the approach to the diverticulum is controversial, with the greatest concern being whether or not to add a right thoracotomy to the median sternotomy for distal anastomosis. We successfully performed total arch replacement through a median sternotomy only, by referring to preoperative computed tomography. We think that if the aneurysm is in a shallow position from the tracheal bifurcation, total arch replacement is possible with a midline incision only.

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.

Two-Stage Hybrid Repair in a Patient with Acute Type A Aortic Dissection Associated with Right Aortic Arch with Aberrant Left Subclavian Artery Originating from a Kommerell Diverticulum

Right aortic arch with aberrant left subclavian artery and Kommerell diverticulum are rare anomalies. A 42-year-old man was referred with sudden-onset chest pain. Enhanced computed tomography (CT) showed a right aortic arch with early thrombosed acute type A aortic dissection and an aberrant left subclavian artery arising from a Kommerell diverticulum. Medical therapy was instituted; however, follow-up CT revealed an ulcer-like projection. The patient was managed with a two-stage hybrid procedure comprising total arch replacement and endovascular repair and experienced no postoperative complications. Two-stage hybrid repair is a safe and effective surgical option for rare complex aortic anomalies.

Single-Stage Total Arch Replacement Including Resection of Kommerell Diverticulum in a Patient With Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is an autosomal dominant genetic connective tissue disorder associated with aortic aneurysmal disease. Kommerell diverticulum (KD) is a rare aortic diverticulum, for which the indication for surgery and the surgical techniques remain subjects of debate. We describe our experience with a successful total aortic arch replacement including KD resection through a median sternotomy for a pediatric patient with LDS.

Thrombosis of Kommerell's diverticulum with subclavian steal phenomenon in a patient with non-small cell lung carcinoma under chemotherapy

Kommerell’s diverticulum (KD) is defined as a bulbous dilatation of the origin of an aberrant subclavian artery due to a remnant of the left fourth aortic arch. We report the case of an asymptomatic woman in whom progressive thrombosis of the KD extending to the prevertebral tract of an aberrant right subclavian artery was detected at multidetector computed tomography imaging for lung cancer staging performed before and after the beginning of chemotherapy. Reversed blood flow in the ipsilateral vertebral artery due to subclavian steal phenomenon was also observed by color Doppler ultrasound examination.

Left thoracoscopic two-stage repair of tracheoesophageal fistula with a right aortic arch and a vascular ring

A right aortic arch (RAA) is found in 5% of neonates with tracheoesophageal fistulae (TEF) and may be associated with vascular rings. Oesophageal repairs for TEF with an RAA via the right chest often pose surgical difficulties. We report for the first time in the world a successful two-stage repair by left-sided thoracoscope for TEF with an RAA and a vascular ring. We switched from right to left thoracoscopy after finding an RAA. A proximal oesophageal pouch was hemmed into the vascular ring; therefore, we selected a two-stage repair. The TEF was resected and simple internal traction was placed into the oesophagus at the first stage. Detailed examination showed the patent ductus arteriosus (PDA) completing a vascular ring. The subsequent primary oesophago-oesophagostomy and dissection of PDA was performed by left-sided thoracoscope. Therefore, left thoracoscopic repair is safe and feasible for treating TEF with an RAA and a vascular ring.

Axillary Artery Cannulation in Acute Aortic Dissection: A Word of Caution

Arterial cannulation into the right axillary artery is a commonly adopted perfusion strategy in the treatment of acute aortic dissection. Here we describe our experience of accidentally cannulating the axillary artery in a case of acute aortic dissection with an aberrant right subclavian artery, which was missed preoperatively because its proximal segment was malperfused by the dissection and thereby not enhanced. The rapid hemodynamics collapse at the start of the bypass was reversed by prompt switching to femoral perfusion. Postoperative follow-up computed tomographic angiography revealed a well-perfused right aberrant subclavian artery. Surgeons should be aware of an aortic arch anomaly whenever performing an axillary artery cannulation.

Persistent right aortic arch with an aberrant left subclavian artery, Kommerell's diverticulum and bicarotid trunk in a 3-year-old cat

Case summary

A 3-year-old male, neutered, domestic shorthair cat with a history of chronic regurgitation since being obtained as a kitten was presented for weight loss and regurgitation of all ingested food. The cat was in poor body condition and had a firm swelling in the ventral neck at the time of presentation. Thoracic radiographs showed severe dilation of the entire cervical and cranial intrathoracic esophagus to the level of the heart base. Computed tomographic angiography (CTA) showed a persistent right aortic arch with an aberrant left subclavian artery and severe dilation of the cervical and intrathoracic esophagus cranial to the heart base. CTA also showed a bicarotid trunk and Kommerell’s diverticulum to be present, which are rare vascular structures in the cat. Esophagoscopy showed esophageal dilation and multiple compact trichobezoars obstructing the esophagus. Removal of the obstructing trichobezoars resulted in resolution of clinical signs, and the cat was able to drink water and eat a canned food slurry without regurgitation. Surgical correction was not pursued.

Relevance and novel information

Vascular ring anomaly (VRA) should be considered in all cats with a history of regurgitation, regardless of their age at the time of presentation. CTA is a valuable diagnostic imaging procedure that allows differentiation of a VRA from other causes of esophageal obstruction and provides information about the VRA that can be used to determine amenability to surgical correction.