Endovascular repair of a Kommerell diverticulum anomaly

The Chimney/Periscope Technique as Total Endovascular Treatment of Kommerell's Diverticulum

We report a case of Kommerell's diverticulum (KD) treated with a total endovascular approach, maintaining supra-aortic trunk (SAT) patency. A 75 year-old female with aneurysmal KD was deemed unsuitable for open surgery. Landing zone 2 was unfeasible; therefore, we planned an endovascular approach with landing in zone 1, chimney to left subclavian artery and periscope to right subclavian artery. Postoperatively she was free from complications, with complete exclusion of KD and SAT patency at 3-year follow-up.

A Systematic Review of Total Thoracic Endovascular Aortic Repair in Treatment of Kommerell Diverticulum Combined with Right-Sided Aortic Arch

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.

Safety and efficacy of a hybrid approach for repair of complicated aberrant subclavian arteries

OBJECTIVE

Aberrant subclavian artery (ASA), a well-described aortic arch anomaly, is frequently associated with dysphagia and development of Kommerell diverticulum (KD) with aneurysmal degeneration. Historically, open repair has been performed, which can be associated with significant morbidity. More recently, hybrid approaches using different arch vessel revascularization techniques in combination with thoracic endovascular aortic repair (hybrid TEVAR) have been described, but there is a paucity of literature describing outcomes. The objective of this analysis was to describe our experience with management of complicated ASAs using hybrid TEVAR, further adding to the literature describing approaches to and outcomes of hybrid ASA repair.

METHODS

A retrospective, single-institution review was performed of all patients treated for ASA complications using hybrid TEVAR (2002-2018). The primary end point was technical success, defined as absence of type I or type III endoleak intraoperatively and within 30 days postoperatively. Secondary end points included complications, reintervention, and survival. Centerline measurement of KD diameters (maximum diameter = opposing aortic outer wall to diverticulum apex) was employed. Kaplan-Meier methodology was used to estimate secondary end points.

RESULTS

Eighteen patients (1.4% of 1240 total TEVAR procedures; male, 67%; age, 59 ± 13 years) were identified (left-sided arch and right ASA, 94% [n = 17]; right-sided arch and left ASA, n = 1 [6%]; retroesophageal location and associated KD, 100%); median preoperative KD diameter was 60 mm (interquartile range [IQR], 37-108 mm). Operative indications included diverticulum diameter (61%), dysphagia (17%), rupture (11%), rapid expansion (6%), and endoleak after TEVAR (6%). All procedures used some combination of supraclavicular revascularization and TEVAR (staged, 50% [n = 9]), whereas partial open arch reconstruction was used in 17% (n = 3). There were no perioperative deaths or spinal cord ischemic events. Major complications occurred in 22% (n = 4): nondisabling stroke, one; arm ischemia, one; upper extremity neuropathy, one; and iatrogenic descending thoracic aortic dissection, one. Technical success was 83%, but 44% (n = 8) had an endoleak (type I, n = 3; type II, n = 5 [intercostal, n = 2; aneurysmal subclavian artery origin, n = 3]) during follow-up (median, 4 months; IQR, 1-15 months). Two endoleaks resolved spontaneously, three were treated, and three were observed (1-year freedom from reintervention, 75% ± 10%). Median KD diameter decreased by 7 mm (IQR, 1-12 mm), and 78% (n = 14) experienced diameter reduction or stability in follow-up. The 1- and 3-year survival was 93% ± 6% and 84% ± 10%, respectively.

CONCLUSIONS

Hybrid open brachiocephalic artery revascularization with TEVAR appears to be safe and reasonably effective in management of ASA complications as evidenced by a low perioperative complication risk and reasonable positive aortic remodeling. However, endoleak rates raise significant concerns about durability. Therefore, if this technique is employed, the mandatory need for surveillance and high rate of reintervention should be emphasized preoperatively. This analysis represents a relatively large series of a hybrid TEVAR technique to treat ASA complications, but greater patient numbers and longer follow-up are needed to further establish the role of this procedure.

Right Aortic Arch, Kommerell Diverticulum, and Symptomatic Retro-Esophageal Vascular Ring in an Adult (Case Presentation and Review)

A 24 year-old Hispanic man presented with progressive retrosternal chest pain, shortness of breath, and dysphagia. Chest X-ray, computed tomography angiography, and magnetic resonance (MRA) studies were compatible with a right aortic arch and a 3.5-cm descending right aortic Kommerell diverticulum. Barium esophagogram and esophagoscopy demonstrated a constricting band crossing the esophagus at the level of the diverticulum. After discussion with other cardiothoracic surgeons, with a combined 300 years of experience, they reported only 1 other possible such case. Kommerell's diverticula are usually repaired in children and rarely are seen in the adult. Kommerell diverticular treatment options include endovascular stenting, cardiopulmonary bypass with resection and grafting, right thoracotomy, and a cervical approach. Because of the patient's findings of a right arch, a Kommerell diverticulum, and a constricting band causing esophageal compression and respiratory distress, it was felt stenting alone would not relieve his symptoms. Therefore, we used a left third posterior intercostal thoracotomy approach to resect the constricting esophageal band connecting the Kommerell diverticulum to the left subclavian artery and to perform the Kommerell diverticulectomy. Releasing the esophageal and tracheal compressing band and resection of the diverticulum provided complete symptom relief with elimination of the dysphagia, dyspnea, wheezing, and chest pain, using a single surgical procedure.

Single-Stage Surgical Repair of Kommerell Diverticulum with Annuloaortic Ectasia via a Median Sternotomy: Frozen Elephant Trunk Technique with an Antler-Like Shape Reconstruction of Arch Branches

We present here a case of Kommerell diverticulum (KD) with annuloaortic ectasia, in which single-stage surgical repair was performed via a median sternotomy using frozen elephant trunk (FET) technique. We used this technique for the following reasons: firstly, we could perform surgery only via a median sternotomy without thoracotomy; secondly, we were able to deliver the FET using a guidewire through the severely angulated aortic arch. We here investigate this technique as it could potentially be a good treatment option of KD.

Endovascular Treatment for Kommerell's Diverticulum with a Right-Sided Aortic Arch

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.

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.