Emergency aortic arch replacement using the debranch‐first technique with a custom‐made prosthesis

How to Treat Type B Aortic Dissections in the Presence of an Aberrant Right Subclavian Artery: A Systematic Review

An aberrant right subclavian artery (ARSA) is the most common congenital variant of the aortic arch. Usually, this variation is largely asymptomatic, but sometimes it may be involved in aortic dissection (AD). Surgical management of this condition is challenging. The therapeutic options have been enriched in recent decades by establishing individualized endovascular or hybrid procedures. Whether these less invasive approaches bear advantages, and how they have changed the treatment of this rare pathology, is still unclear. Therefore, we conducted a systematic review. We performed a review of literature from the past 20 years (from January 2000 until February 2021) complying with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All reported patients treated for Type B AD in the presence of an ARSA were identified and classified into three groups according to the received therapy (open, hybrid, and total endovascular). Patient characteristics, as well as in-hospital mortality, and major and minor complications were determined and statistically analyzed. We identified 32 relevant publications comprising 85 patients. Open arch repair has been offered to younger patients, but significantly less often in symptomatic patients needing urgent repair. Therefore, the maximum aortic diameter was also significantly larger in the open repair group compared with that in the hybrid or total endovascular repair group. Regarding the endpoints, we did not find significant differences. The literature review revealed that open surgical therapies are preferred in patients presenting with chronic dissections and larger aortic diameters, most likely because they are unsuitable for endovascular aortic repair. Hybrid and total endovascular approaches are more often applied in emergency situations, where aortic diameters remain smaller. All therapies demonstrated good, early, and midterm outcomes. But, these therapies carry potential risks in the long term. Therefore, long-term follow-up data are urgently needed to validate that these therapies are sustainable.

Outcomes of open and endovascular repair of Kommerell diverticulum

OBJECTIVES

Kommerell diverticulum (KD) is a rare congenital vascular anomaly often associated with an aberrant subclavian artery (ASCA). Definitive indications for intervention remain unclear. We present open and endovascular (EV) operative outcomes in a large contemporary series and propose a management algorithm.

METHODS

Between 2004 and 2020, 224 patients presented with ASCA and associated KD to our institution. Of the 43 (19.2%) patients who underwent operative repair, 31 (72.1%) had open surgical (OS) repair via thoracotomy and 12 (27.9%) had EV repair. Univariable and bivariable statistical analyses were conducted stratified by approach. The median follow-up time was 5.4 years (IQR, 2.9-9.7).

RESULTS

Patients in EV group were older (68 years vs 47 years, P < 0.001) and had larger aneurysms (base diameter 3.2 cm vs 21.5 cm, P = 0.007). All patients with dysphagia lusoria were treated with open surgery (n = 20). Asymptomatic patients with incidentally detected KD (50% vs 16.1%), those with chest or back pain (50% vs 19.4%) and patients who presented with an aortic emergency (25% vs 6.5%) were more likely to be treated endovascularly (P = 0.001). Carotid-to-subclavian bypass was used in 38 (88.4%) patients. There were no operative mortalities. In-hospital mortality was similar between groups (3.2% vs 16.7%, P = 0.121). Mid-term mortality was higher in the EV group [4 (33.8%) vs 0, P < 0.001]. There were 2 (15.4%) postoperative strokes in the EV group. There were no statistically significant differences in other postoperative complications or hospital length of stay between groups.

CONCLUSIONS

KD can be managed using open or EV approaches with low morbidity and mortality. Treatment strategy should depend on clinical presentation and patient factors.