Hybrid Treatment for Ruptured Diverticulum of Kommerell: A Minimally Invasive Option

A systematic review of open, hybrid, and endovascular repair of aberrant subclavian artery and Kommerell's diverticulum treatment

BACKGROUND

Aberrant subclavian artery (AScA) with or without associated Kommerell's diverticulum (KD) is the most frequently encountered anomaly of the aortic arch, it may be life threatening, especially when associated with aneurysmal degeneration. The best management is still debated and depends on many clinical and anatomical factors. A systematic review was conducted to assess the current evidence on the treatment options and their efficacy and safety for AscA and KD repairs.

METHODS

A literature search in PubMed and Cochrane Library was performed, and articles that were published from January 1947 to August 2021 reporting on AscA and KD management were identified. Multicenter studies, single-center series, and case series with three or more patients were considered eligible in the present review. A comparison of outcomes of patients who underwent open surgery (OS), a hybrid approach (HA), and total endovascular repair (ER) (ie, 30-day mortality and stroke were analyzed when available and compared among the three groups (P < .05; Benjamini and Hochberg-adjusted P < .05; Bonferroni-adjusted P < .05). Titles, abstracts, and full texts were evaluated by two authors independently. Primary outcomes included survival rate, perioperative stroke, arm ischemia, and spinal cord ischemia. Endoleak, in the case of HA and ER, and reintervention rates were considered outcomes.

RESULTS

Three hundred thirty-one articles were initially evaluated and 30 studies, totaling 426 patients treated for AScA with 324 KD, were included. Of the 426 patients, 241 were male (56.5%), and the mean patient age was 57.9 ± 12.0 years. The approach was OS in 228 patients, HA in 147 patients, and ER in 51. Dysphagia was the most common presentation in 133 cases. Aortic rupture was observed in 16 of the 426 patients (3.8%), including 14 AScA/KD (3.3%) aneurysm rupture. KD maximum diameter varied widely from 12.6 to 63.6 mm. The overall 30-day mortality was 20 (4.7%) (OS group 8/228 [3.5%]; HA group 10/147 [6.8%]; ER 2/51 [3.9%]; P = NS). The overall stroke rate was 4.9% (21/426) (OS group 10/228 [4.4%]; HA group 6/147 [4.1%]; ER group 5/51 [9.8%]; P = NS), including nine transient and nondisabling neurological deficits. Overall secondary procedures for complications were reported in 36 of the 426 cases (8.4%), mostly owing to endoleak. Follow-up varied from 13 to 74 months.

CONCLUSIONS

This systematic review assessed the current outcomes of the three types of therapeutic management for AScA and KD and demonstrated that they are all relatively safe and effective, providing satisfactory early and midterm outcomes. Long-term outcomes are warranted, especially for total ERs since the long-term durability of stent grafts remains unknown.

A Rare Case of Submassive Pulmonary Embolism with a Right Aberrant Subclavian Artery and Thrombosed Kommerell Diverticulum

An 81-year-old man presented with shortness of breath and was referred to our hospital with suspected acute pulmonary embolism. Enhanced computed tomography revealed a right aberrant subclavian artery with a thrombosed Kommerell diverticulum (KD), as well as deep vein thrombosis in the left leg and bilateral pulmonary artery thrombosis. Thrombosis in the KD disappeared after one month of anticoagulation treatment with rivaroxaban. Thrombosis of a KD is a rare condition that may cause distal emboli and subclavian steal syndrome, although this syndrome was not present in this case. Rivaroxaban is an effective anticoagulant for treating thrombosis of a KD.

Hybrid Repair of Kommerell's Diverticulum with Embolization of Aberrant Left Subclavian Artery

An asymptomatic 70-year-old man presented with Kommerell’s diverticulum (KD) and an aberrant left subclavian artery. Computed tomography revealed a KD diameter of 53 mm, severe aortic arch angulation, and no landing zone for thoracic endovascular aortic repair from the arch vessels to the diverticulum. We performed single-stage hybrid repair of KD of the right aortic arch, left carotid–left subclavian artery bypass, and embolization of the subclavian artery, followed by replacement of the descending aorta through deep hypothermic circulatory arrest via right thoracotomy. He was discharged home without any symptoms and remained uneventful at 1 year after the operation.

Intrapericardial rupture of distal aortic arch aneurysm

Intrapericardial rupture of an aortic arch aneurysm is a rare and catastrophic event that requires emergency treatment. Recent development of thoracic endovascular repair has contributed to improved outcomes for the treatment of ruptured aneurysm of the thoracic aorta. However, when there is an aneurysm that involves the arch vessels, the treatment strategy, including conventional open surgery and endovascular stenting, is still controversial. We performed life-saving emergency total arch replacement using a modified elephant-trunk procedure for two cases of intrapericardial rupture of an aortic arch aneurysm. Prompt institution of cardiopulmonary bypass is effective for reducing the risk of re-rupture. Hybrid operation caries the risk of re-rupture during the procedure because it is performed under heparinization without blood pressure control. Open surgery is still a good option for such cases.

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.

Hybrid management of a ruptured right subclavian artery aneurysm dissection

Aberrant right subclavian artery is the most common congenital malformation of the aortic arch (0.4%-2.0%). Aneurysms of aberrant subclavian arteries are extremely rare. This results in little experience with their treatment. We describe a case of a patient who presented to the emergency department with a dissection of an aberrant right subclavian artery that later progressed to rupture. Besides hemodynamic instability, this caused an acute superior vena cava syndrome, making airway control difficult. In the operating room, we obtained proximal control through thoracic endovascular aortic repair; median sternotomy was performed for distal control and evacuation of massive hemomediastinum.

Random Finding of a Ruptured Kommerell Aneurysm After Stroke

The random finding of a ruptured Kommerell aneurysm (rKA) is exceptional. We report the case of a 74-year-old man who received an incidental diagnosis of a contained rKA involving an aberrant right subclavian artery after a stroke. He underwent successful hybrid repair with the use of thoracic endovascular aortic repair associated with cervical debranching of the left subclavian artery and vascular plug occlusion of both subclavian artery origins. Whereas no early adverse event was reported, the patient experienced a vertebrobasilar insufficiency once he had recovered, requiring an additional right carotid-to-subclavian bypass.

Preemptive Aneurysm Sac Embolization for Thoracic Endovascular Aortic Repair With Inadequate Proximal Landing Zone

Thoracic endovascular aortic repair (TEVAR) offers a less invasive treatment for aortic arch aneurysms. Clinical challenges arise when there is inadequate proximal landing for zone 1 TEVAR, such that a median sternotomy with total aortic debranching is required before stent deployment. The chimney technique was reported as an alternative approach to stent the arch branches and avoid sternotomy, but it was still associated with considerable chance of a type IA endoleak. We report a case of aortic arch aneurysm with an inadequate proximal landing for zone 1 TEVAR that was treated with debranching of head and neck vessels followed by TEVAR and preemptive and targeted coil embolization of the arch aneurysmal sac. Postoperative computed tomography showed no significant endoleak, and the patient had an unremarkable recovery.

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.

Endovascular repair of a Kommerell diverticulum anomaly

A Kommerell diverticulum (KD) may predispose toward aortic aneurysm, dissection, or rupture, although they are primarily asymptomatic. We report a case of an aberrant left subclavian artery arising from a KD in a right-side aortic arch. The lesions were successfully treated by an endovascular approach involving Amplatzer vascular plug embolization of the aberrant left subclavian artery and endovascular repair of the KD.

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

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.