Hybrid endovascular treatment of aneurysm degeneration in a rare right-aortic arch anomaly with Kommerell diverticulum

Two-year follow-up after treatment of an aortic transection in the presence of an aberrant right subclavian artery

OBJECTIVES

An aberrant right subclavian artery (ARSA) is one of the most common anatomic variants of the aortic arch. The combination of an ARSA and a transection is naturally rare.

METHODS

This case report describes the treatment of a transection in the presence of an ARSA and the follow-up of two years.

RESULTS

We successfully treated the contained rupture with a stentgraft. Both subclavian arteries had to be covered in the emergency setting. At the two-year follow-up, the patient did not suffer from any neurological impairment.

CONCLUSIONS

In emergency settings, primary cover of both subclavian arteries with a stentgraft can be performed in individual cases after risk assessment. Severe complications such as development of upper limb ischaemia, ASAS or reduced perfusion of the posterior cerebral circulation should be considered in treatment planning.

Total arch replacement with frozen elephant trunk technique for Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery

BACKGROUND

Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery is uncommon. We perforemed a single-stage procedure with the frozen elephant trunk technique.

CASE PRESENTATION

A 62-year-old man underwent aortic dissection a year ago, and computerized tomographic angiography performed at that time revealed a right aortic arch, Kommerell's diverticulum (42 mm), and an aberrant left subclavian artery. We performed one-stage repair through median sternotomy. The cervical branches were exposed during the operation, and a deep hypothermic circulatory arrest with antegrade cerebral perfusion was established. The aorta was transected distally to the origin of the left carotid artery. We inserted a stent graft into the aorta, followed by peripheral anastomosis using a premade 5-branch Dacron graft. The right subclavian artery and the aorta were reconstructed, and the remaining cervical branches were reconstructed after the cross-clamp had been released.

CONCLUSIONS

Total arch replacement through median sternotomy was performed for the right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. The frozen elephant trunk technique is allowed to perform a one-stage operation safely.

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.

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.

Single-Stage Total Arch Replacement With Open Stent Graft for Kommerell's Diverticulum With Right-Sided Aortic Arch

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

A review of the surgical management of right-sided aortic arch aneurysms

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.

One-stage hybrid procedure for aberrant right subclavian artery and thoracic aneurysm

A 60-year-old man without any symptoms was referred to our department because computed tomography revealed an aberrant right subclavian artery (ARSA) and a saccular aortic aneurysm arising opposite to the ARSA. We performed the following procedures through a median sternotomy: total arch replacement, insertion of a frozen elephant trunk to exclude the aneurysm and ARSA, placement of a vascular plug under transesophageal ultrasonography to occlude the dilated ARSA, and right axillary artery bypass. Postoperative computed tomography showed complete occlusion of the ARSA and exclusion of the aneurysm. This procedure should be considered an alternative strategy for treatment of patients with an ARSA.

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.

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

BACKGROUND

Aortic dissection involving a right-sided aortic arch (RAA) associated with Kommerell's diverticulum is extremely rare and remains a complicated entity for surgical therapy because of its anatomical characteristics. Fewer than 40 cases have been reported in the English language literature to date.

METHODS

We reported a case of 69-year-old male patient who presented with acute type B aortic dissection involving an RAA associated with Kommerell's diverticulum, a stent-graft was accurately deployed and embolization of the left subclavian artery. In addition, a review of the literature was performed to examine its clinical presentation and the efficacy of management strategies.

RESULTS

One year follow-up showed positive aortic remodeling with exclusion of Kommerell's diverticulum and thrombosis of the false lumen.

CONCLUSIONS

An aortic dissection involving an RAA associated with Kommerell's diverticulum is an extremely rare condition. Endovascular therapy is technically feasible when the dissection involves this unusual vascular malformation.

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.

Two cases of thoracic aortic aneurysm with right aortic arch: comparison of two operative strategies for hybrid thoracic endovascular repair

Hybrid TEVAR was performed in 2 patients with right aortic arch accompanied by Kommerell's diverticulum and aortic aneurysm. In patient 1, total debranch + TEVAR was performed with 1-stage median sternotomy. In patient 2, total arch replacement and insertion of a peripheral elephant trunk were performed first, followed by TEVAR. No endoleaks or aortic events were observed in either case during the observation period, and both patients had good postoperative clinical courses. We report our experience with two such cases that were treated with two different methods of hybrid TEVAR, and discuss the merits and demerits of each treatment method.

A case of type-2 endoleak from a bronchial artery after endovascular aortic repair for Kommerell diverticulum

We describe a case of type-2 bronchial artery endoleak after endovascular aortic repair of Kommerell diverticulum (KD) involving right-sided aortic arch and aberrant left subclavian artery (LSA). A 68-year-old woman underwent an endovascular repair of KD with an aberrant LSA in our hospital. Follow-up computed tomography (CT) at 6 months after the procedure showed an endoleak. Digital subtraction angiography revealed a type-2 endoleak from a bronchial artery, but no type-1 or type-2 endoleak from the aberrant left subclavian artery. We performed coil embolization of the KD and the left subclavian artery. The endoleak disappeared in the postoperative CT.

Hybrid repair of right aortic arch aneurysm with a Kommerell's diverticulum

We describe the case of a 74-year-old man who underwent a hybrid open and endovascular approach for repair of dissecting thoracic aortic aneurysm of a right aortic arch with aberrant left subclavian artery arising from a Kommerell's diverticulum. Total debranching using a tailored quadrifurcated graft and thoracic endovascular aneurysm repair for the transverse aortic lesion were performed. The procedures were successfully accomplished with complete exclusion of the aneurysm. This hybrid procedure for complex aortic arch disease may reduce perioperative complications compared to challenging conventional open approaches.

Endovascular repair of a right-sided thoracic aortic aneurysm with Kommerell diverticulum and aberrant left subclavian artery

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.

Hybrid endovascular treatment of an aberrant right subclavian artery with Kommerell aneurysm

Aberrant right subclavian artery is a rare anatomical finding of abnormal embryologic development of the dorsal aorta and right subclavian artery. An associated aortic outpouching, or Kommerell diverticulum, may develop at the origin of the aberrant right subclavian artery. Given historically high rates of aneurysm rupture and mortality, early repair is indicated. Successful aneurysm exclusion can be accomplished with thoracic endovascular stent grafting following open carotid-subclavian bypass, maintaining upper extremities perfusion. Such hybrid techniques offer a decrease in mortality and complication rates. Herein, we describe a successful repair of a symptomatic (dysphagia, weight loss) aberrant right subclavian artery with Kommerell diverticulum using this hybrid open-endovascular approach.

Transaortic stent grafting of a Kommerell diverticulum arising from a right-sided aortic arch

In this article, we report the case of a 68-year-old woman who presented with shortness of breath. Respiratory function tests showed a slightly obstructive physiology. Computed tomography (CT) results revealed an aberrant left subclavian artery and a Kommerell diverticulum arising from a right-sided aortic arch that was compressing the trachea and the surrounding tissues. A median sternotomy was performed with the patient under circulatory arrest with moderate hypothermia, and a transaortic stent graft was inserted to exclude the Kommerell diverticulum. The aberrant left subclavian artery was ligated and an axillo-axillar bypass was constructed. Postoperative CT showed complete exclusion of the Kommerell diverticulum without an endoleak. The patient's breathing difficulty was resolved, and she was discharged uneventfully. This procedure should be considered as an alternative strategy for exclusion of Kommerell diverticulum.

Computed tomography angiography of hybrid thoracic endovascular aortic repair of the aortic arch

Endovascular repair of the aorta has traditionally been limited to the abdominal aorta and, more recently, the descending thoracic aorta. However, recently hybrid repairs (a combination of open surgical and endovascular repair) have made endovascular repair of the aortic arch possible. Hybrid repair of the aortic arch typically involves an open surgical debranching procedure that allows for revascularization of the aortic arch vessels and subsequent endovascular stent placement. These approaches avoid the deep hypothermic circulatory arrest required for full, open surgical repair of the aortic arch. In hybrid repairs, the stent landing zone determines which branch vessels will be covered and therefore need revascularization. This article will review the preprocedure assessment with computed tomography angiography, techniques for revascularization and postprocedure complications.

Surgical treatment of Kommerell's diverticulum and other saccular arch aneurysms

BACKGROUND

Saccular aneurysms of the aortic arch are rare, and their surgical repair is challenging with potentially significant morbidity and mortality.

METHODS

We examined our experience over a 3-year period with nine consecutive patients that include nine hybrid repairs with initial extra-anatomic carotid and/or subclavian bypass and subsequent endovascular exclusion of the saccular arch aneurysm.

RESULTS

Three patients presented with dysphagia from aberrant right subclavian arteries with aneurysm at the origin of the artery, two had asymptomatic aneurysms at the origin of the left subclavian, and four patients had isolated saccular aneurysms of the arch, three of whom presented with thoracic pain. A total of 16 extra-anatomic bypasses were done in the nine patients. Ten endografts and one nitinol plug were used for exclusion in the nine hybrid cases. There were no perioperative deaths, no strokes, or myocardial infarction events. During follow-up, two patients (22%) were found to have type II endoleaks, but no reinterventions were required. Symptoms resolved in six patients, whereas persistent dysphagia and pain occurred in one.

CONCLUSIONS

Repair of saccular aneurysms of the aortic arch by hybrid approach can be done with minimal morbidity and mortality and a reasonable rate of symptom resolution.

Total endovascular repair of aberrant left subclavian artery with Kommerell's diverticulum using a customized branched device

We describe a case of Kommerell's diverticulum involving the distal portion of a right-sided aortic arch and the origin of an aberrant left subclavian artery (LSA). The patient underwent a total endovascular repair with the use of a modified Valiant endograft (Medtronic, Minneapolis, Minn) to which a branch was attached to keep LSA patency. Postoperative computed tomography showed complete exclusion of the lesion, without endoleaks. The use of "customized off-label" devices to treat special conditions was feasible in this case, keeping patency of the LSA without risk of arm claudication or the requirement for a complementary surgical bypass.

Aberrant left subclavian artery associated with a Kommerell's diverticulum and a left-sided aortic arch

Kommerell's diverticulum is most commonly associated with either an aberrant left subclavian artery from a right-sided aortic arch or an aberrant right subclavian artery from a left-sided aortic arch. We describe an exceedingly rare case of an aberrant left subclavian artery arising from a Kommerell's diverticulum in a patient with a left-sided aortic arch, the "nonaberrant aberrant left subclavian artery."