Endovascular Treatment for Acute Type B Aortic Dissection Involving a Right-sided Aortic Arch and Kommerell's Diverticulum: A Case Report and Review of the Literature

Right-sided aortic arch with Kommerell’s diverticulum: a case report of a rare cause of type B dissection

Background

A right-sided aortic arch (RAArch) is present in approximately 0.1% of the population. A Kommerell’s diverticulum (KD), a remnant of the dorsal aortic arch usually refers to an aneurysmal aortic enlargement at the origin of an aberrant left subclavian artery (ALSA) and is associated with an increased risk of aortic dissection.

Case summary

A 59-year-old female smoker with a history of hypertension and hypercholesterolaemia presented with a 24-hour history of sudden-onset and severe stabbing chest pain radiating to the interscapular region. Physical examination was normal except for bilateral basal crepitations. Computed tomography angiography (CTA) showed a type B aortic dissection in a RAArch with an ALSA arising from KD with a peri-aortic haematoma and haemothorax without any active contrast extravasation. After medical stabilization, a semi-urgent hybrid repair was performed with a right carotid-subclavian bypass, thoracic endovascular aortic repair (TEVAR), a plug in the left subclavian artery, and left carotid-subclavian bypass due to severe ischaemia of the left arm. The postoperative CTA showed patent bypasses, aortic remodelling, and a minimal type IIa endoleak at the level of the ALSA.

Discussion

In patients with a type B dissection and KD, hybrid repair including TEVAR is feasible after careful pre-operative assessment of the patient’s unique anatomy and may reduce post-surgical morbidity and mortality compared to open surgery. Prophylactic repair may be considered in patients with an asymptomatic RAArch and KD.

Modified use of a 4-branched frozen elephant trunk prosthesis for treatment of a right-sided aortic arch aneurysm with an aberrant left subclavian artery

Right aortic arch aneurysm originating from a Kommerell's diverticulum associated with an aberrant left subclavian artery is a rare congenital entity. We report a case of an asymptomatic 60-year-old female with right aortic arch aneurysm with an aberrant left subclavian artery, treated with a modified frozen elephant trunk technique using a 4-branched prosthesis, with the perfusion branch as an extra-anatomical bypass to the aberrant left subclavian artery. This case demonstrates short-term safety and efficacy of this technique.

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.

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.