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Nakamura Y, Kumada Y, Mori A, Kawai N, Ishida N, Kasugai T. Thoracic endovascular aortic repair for chronic aortic dissection after total arch replacement for aberrant right subclavian artery: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221123432. [PMID: 36119664 PMCID: PMC9478695 DOI: 10.1177/2050313x221123432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022] Open
Abstract
An aberrant right subclavian artery (ARSA) is an extremely rare congenital anomaly that forms during aortic arch development. Most reports of thoracic endovascular aortic repair (TEVAR) described an ARSA in the right aortic arch, but it is rare in the left aortic arch. We present the case of a 66-year-old man who underwent total arch replacement because of acute type A aortic dissection. An outpatient follow-up examination revealed that the aortic diameter enlargement exceeded 60 mm because of false lumen entry from the ARSA. Therefore, surgical intervention was planned. TEVAR, ARSA embolization, and bilateral axillary bypass surgery were successfully performed for a chronic dissecting aortic aneurysm for which the ARSA was the inflow route. He was discharged 12 days after surgery. Four years later, no enlargement of the aneurysm diameter was observed. TEVAR is a minimally invasive and useful treatment option for chronic type B dissections with an ARSA associated with the left aortic arch; however, patients with an ARSA have fragile blood vessels and require careful follow-up.
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Affiliation(s)
- Yasuhito Nakamura
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Yoshitaka Kumada
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Akihiro Mori
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Norikazu Kawai
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Narihiro Ishida
- Department of Cardiovascular Surgery, Matsunami General Hospital, Gifu, Japan
| | - Toshio Kasugai
- Department of Chest Surgery, Matsunami General Hospital, Gifu, Japan
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Fan W, Tan J, Shi W, Rong J, Yu B. A Systematic Review of Total Thoracic Endovascular Aortic Repair in Treatment of Kommerell Diverticulum Combined with Right-Sided Aortic Arch. Med Sci Monit 2021; 27:e930031. [PMID: 33755659 PMCID: PMC7999715 DOI: 10.12659/msm.930031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Kommerell diverticulum (KD) combined with right-sided aortic arch (RAA) and aberrant left subclavian artery (ALSA) are rare and limited to a few case reports and small series. Thoracic endovascular aortic repair (TEVAR), which is mini-invasive, is widely utilized in complicated aortic disease. We performed a systematic review of the literature to identify all patients who underwent endovascular repair for KD in terms of technical feasibility and procedural outcomes. Published and accepted studies only in English as well as article reference lists were searched and extracted to assess case series reporting solely TEVAR in KD patients. There were 28 patients with KD/RAA identified from 19 studies. All of them underwent endovascular technique for KD exclusion and the median age was 69 years (range 39-83 years). Hypertension (n=17) was the most common comorbidity in this cohort, followed by diabetes mellitus (n=3), hyperlipidemia (n=3), and smoking (n=3). The presenting symptoms were dysphagia (n=8, 29%), intermittent back pain (n=4, 14%), and acute aortic dissection (n=6, 21%), while asymptomatic was found in 9 patients (n=9, 32%). A technical success rate of 100% was reported associated with various managements of ALSA, proximal embolization (n=19, 68%), in-situ revascularization (n=3, 11%), and left carotid-subclavian bypass (n=3, 11%). All patients survived without severe complications and were discharged home within less than 14 days. The mean follow-up time was 9.3 months, patency was found in all patients, thrombosis and distinct shrinkage of KD aneurysm as indicated by CT-scans were noted (n=20, 71%), and type II endoleak was found in only 4 patients (n=4, 14%). TEVAR appears to be safe and offers favorable results, but it still needs substantial evidence to support routine use in KD. TEVAR is an alternative to open repair in selected cases, but it needs further investigation in a large cohort.
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Affiliation(s)
- Weijian Fan
- Department of Vascular Surgery, Suzhou Traditional Chinese medicine (TCM) Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, Jiangsu, China (mainland).,Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China (mainland)
| | - Jinyun Tan
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China (mainland)
| | - Weihao Shi
- Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China (mainland)
| | - Jianjie Rong
- Department of Vascular Surgery, Suzhou Traditional Chinese medicine (TCM) Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, Jiangsu, China (mainland)
| | - Bo Yu
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China (mainland).,Department of Vascular Surgery, Huashan Hospital of Fudan University, Shanghai, China (mainland)
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Hara M, Fujii T, Kawasaki M, Katayanagi T, Okuma S, Shiono N, Tokuhiro K, Watanabe Y. Endovascular Treatment for Kommerell's Diverticulum with a Right-Sided Aortic Arch. Ann Vasc Dis 2017; 10:74-76. [PMID: 29034028 PMCID: PMC5579789 DOI: 10.3400/avd.cr.16-00101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/20/2017] [Indexed: 11/13/2022] Open
Abstract
We report a rare case of type A dissection involving a right-sided aortic arch with an aberrant left subclavian artery originating from Kommerell's diverticulum in a 76-year-old woman. Endovascular treatment for Kommerell's diverticulum including intimal tear of the dissection was performed. At the 5-year follow-up, the patient was doing well, with no endoleak or dilatation of the Kommerell's diverticulum.
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Affiliation(s)
- Masanori Hara
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - Takeshiro Fujii
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - Muneyasu Kawasaki
- Department of Cardiovascular Surgery, Misato Central General Hospital, Misato, Saitama, Japan
| | - Tomoyuki Katayanagi
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - Shinnosuke Okuma
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - Noritsugu Shiono
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
| | - Keiichi Tokuhiro
- Department of Cardiovascular Surgery, Misato Central General Hospital, Misato, Saitama, Japan
| | - Yoshinori Watanabe
- Division of Cardiovascular Surgery, Toho University Medical Center Omori Hospital, Tokyo, Japan
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Barr JG, Sepehripour AH, Jarral OA, Tsipas P, Kokotsakis J, Kourliouros A, Athanasiou T. A review of the surgical management of right-sided aortic arch aneurysms. Interact Cardiovasc Thorac Surg 2016; 23:156-62. [PMID: 27001673 DOI: 10.1093/icvts/ivw058] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/19/2015] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- James G Barr
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, London, UK
| | - Amir H Sepehripour
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Omar A Jarral
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Pantelis Tsipas
- Department of Cardiothoracic Surgery, Evangelismos Hospital, Athina, Greece
| | - John Kokotsakis
- Department of Cardiothoracic Surgery, Evangelismos Hospital, Athina, Greece
| | - Antonios Kourliouros
- Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, London, UK
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Tanaka A, Milner R, Ota T. Kommerell's diverticulum in the current era: a comprehensive review. Gen Thorac Cardiovasc Surg 2015; 63:245-59. [PMID: 25636900 DOI: 10.1007/s11748-015-0521-3] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 11/30/2022]
Abstract
Kommerell's diverticulum is a developmental error with a remnant of fourth dorsal aortic arch, named after Dr. Kommerell, a radiologist, who made the first diagnosis in a living individual. The diverticulum can occur in both the left and right aortic arch, from which an aberrant subclavian artery rises to the contralateral side. Pediatric patients often present with airway symptoms whereas dysphagia and chest discomfort are more common in the adult patients. Computed tomography or magnetic resonance imaging can provide details of the diverticulum, associated arch anomalies, and its relationship with surrounding organs. Recent histological studies indicated the presence of cystic medial necrosis in the diverticulum wall, which would explain the reported high rates of aortic dissection and rupture associated with the diverticulum. Accumulated knowledge on this entity and the recent advancement of imaging techniques, surgical/endovascular strategies, and perioperative management, have led to more aggressive intervention to the diverticulum in the early phase. While still under debate it is generally accepted to consider surgical intervention when the diameter of the diverticulum orifice exceeds over 30 mm, and/or the diameter of the descending aorta adjacent to the diverticulum exceeds over 50 mm. Treatment options include open surgical repair, hybrid endovascular repair, and total endovascular repair. The selection of treatment strategy for Kommerell's diverticulum should be based on the anatomy, comorbidities of the patient, and surgical expertise available. The summaries of open and endovascular repairs of over 210 cases from literature search from 2004 to 2014 are also provided in this review.
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Affiliation(s)
- Akiko Tanaka
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago, 5841 Maryland Avenue, Suite E-500/MC5040, Chicago, IL, 60637, USA
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Endovascular repair of thoracic aortic aneurysm associated with right-sided aortic arch: report of two cases. Gen Thorac Cardiovasc Surg 2014; 64:552-7. [PMID: 25547542 DOI: 10.1007/s11748-014-0514-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 12/23/2014] [Indexed: 10/24/2022]
Abstract
Right-sided aortic arch (RAA) is a rare congenital disorder. We describe herein two cases of thoracic aortic aneurysm with a right aortic arch and right-sided descending aorta treated with thoracic endovascular aortic repair (TEVAR). In one case, a 70-year-old man with Edwards type 1 RAA underwent TEVAR using a Relay stent-graft (Bolton Medical, Barcelona, Spain). In another case, a 72-year-old woman with Edwards type 3 RAA underwent TEVAR using a Kawasumi Najuta stent-graft (Kawasumi Laboratories, Inc., Tokyo, Japan) with the "buffalo horn chimney technique", our original method for left subclavian artery flow preservation. The postoperative courses were uneventful. Postoperative computed tomography showed complete exclusion of the aneurysm without endoleakage. Compared to conventional open surgical repair, TEVAR is challenging in patients with a RAA and right-sided descending aorta. However, our results showed that TEVAR might be feasible and a treatment option even in a patient with a RAA and right-sided descending aorta.
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Monaco M, Lillo S, La Marca Giordano A, Contaldo A, Schiavone V. Endovascular repair of a right-sided thoracic aortic aneurysm with Kommerell diverticulum and aberrant left subclavian artery. Ann Vasc Surg 2014; 28:1323.e1-5. [PMID: 24534686 DOI: 10.1016/j.avsg.2014.01.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 01/06/2014] [Accepted: 01/12/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND A case of successful total endovascular repair of a right-sided descending thoracic aorta aneurysm (r-DTAA) with Kommerell diverticulum and aberrant left subclavian artery (ALSA) was reported. Few cases of this very rare pathology were reported, mostly describing a hybrid treatment, with only 2 cases of total endovascular repair performed to date. METHODS AND RESULTS Our strategy consisted of endovascular ALSA occlusion, without preventive revascularization, and r-DTAA exclusion by 2 endoprosthesis implanted in a telescopic fashion, first the distal one, to achieve a relative straightening of the arch and support the proximal endoprosthesis, and then the proximal one, close to the right subclavian origin. Completion angiography and 12-month computed tomography scan showed successful exclusion, patency of epiaortic vessels, and absence of endoleak. CONCLUSION Endovascular repair can be a safe and effective treatment for aortic disease with challenging anatomy, avoiding the need for a complex open surgery procedure.
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Affiliation(s)
- Mario Monaco
- Department of Vascular Surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy.
| | - Stefano Lillo
- Department of Vascular Surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | | | - Antonio Contaldo
- Department of Vascular Surgery, Pineta Grande Hospital, Castelvolturno (CE), Italy
| | - Vincenzo Schiavone
- Department of Anesthesiology, Pineta Grande Hospital, Castelvolturno (CE), Italy
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Andersen ND, Barfield ME, Hanna JM, Shah AA, Shortell CK, McCann RL, Hughes GC. Intrathoracic subclavian artery aneurysm repair in the thoracic endovascular aortic repair era. J Vasc Surg 2013; 57:915-25. [DOI: 10.1016/j.jvs.2012.09.074] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
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Croccia MG, Levantino M, Cioni R, Bortolotti U. Endovascular stenting for type B dissection involving a right-sided aortic arch. Interact Cardiovasc Thorac Surg 2012; 15:304-6. [PMID: 22561295 DOI: 10.1093/icvts/ivs153] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Endovascular stent-graft repair is emerging as the treatment of choice for complicated type B aortic dissection. In this report we describe a patient who presented with type B aortic dissection involving a right-sided aortic arch (RAA), a rare congenital vascular anomaly. The initial aggressive medical treatment proved unsuccessful due to false aneurysm expansion. Given the greater complexity of conventional surgical repair and the limited experience with this rare malformation, endovascular repair was preferred and successfully performed. We report the first case of endovascular repair of type B dissection involving RAA, confirming that endovascular treatment is technically feasible also when the dissection involves this unusual vascular malformation.
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Affiliation(s)
- Maria Grazia Croccia
- Department of Cardiothoracic and Vascular Surgery, University of Siena Medical School, Siena, Italy
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10
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Open techniques for arch vessel reconstruction during thoracic endovascular aneurysm repair (TEVAR). J Vasc Surg 2010; 52:71S-6S. [DOI: 10.1016/j.jvs.2010.06.146] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 06/14/2010] [Accepted: 06/17/2010] [Indexed: 11/23/2022]
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Lee CY, Moraca RJ, Benckart DH, Bailey SH, Magovern GJ, Muluk S. Thoracic endovascular aortic repair of an aberrant right subclavian artery: technique and long-term outcome. J Card Surg 2010; 25:390-3. [PMID: 20529153 DOI: 10.1111/j.1540-8191.2010.01058.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three-stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long-term clinical and radiographic follow-up.
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Affiliation(s)
- Candace Y Lee
- Department of Cardiovascular and Thoracic Surgery, Allegheny General Hospital, Pittsburgh, PA 15212, USA
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Obitsu Y, Koizumi N, Iwahashi T, Saiki N, Shigematsu H. Surgical repair for aortic dissection accompanying a right-sided aortic arch. J Cardiothorac Surg 2010; 5:35. [PMID: 20459743 PMCID: PMC2880313 DOI: 10.1186/1749-8090-5-35] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 05/10/2010] [Indexed: 11/11/2022] Open
Abstract
Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.
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Affiliation(s)
- Yukio Obitsu
- Department of Vascular Surgery, Tokyo Medical University 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, Japan 160-0023.
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