Endovascular repair of type A aortic intramural hematoma accompanied by aberrant right subclavian artery and Kommerell's diverticulum: a case report

Aberrant right subclavian artery: case report and literature review

The aberrant right subclavian artery, also known as the arteria lusoria, is the most common aortic arch anomaly, occurring in 0.5 to 1% of the population. There is a higher prevalence in women and it is usually associated with other anatomical variations, such as the non-recurrent laryngeal nerve, present in 86.7% of cases. In the majority of cases, the aberrant right subclavian artery causes no symptoms. We describe this anomaly in an 82-year-old, hypertensive, and asymptomatic patient who had undergone a thoracoabdominal angiography to investigate a chronic DeBakey type III aortic dissection with dilation of the descending aorta. The aberrant right subclavian artery followed a retroesophageal course and was associated with a Kommerell diverticulum. In view of its rarity, we conducted an integrative bibliographic review of literature from the last 6 years indexed on the Medline, UpToDate, Lilacs, Scielo, and Portal Capes databases and discuss the most frequent anatomical changes, symptomatology, and therapeutic management adopted.

Artéria subclávia direita aberrante: relato de caso e revisão de literatura

Resumo A artéria subclávia direita aberrante, também conhecida como artéria lusória, é a anomalia do arco aórtico mais comum, ocorrendo entre 0,5 e 1% da população. Possui prevalência em mulheres e normalmente está associada a outras variações anatômicas, como o nervo laríngeo não recorrente, presente em 86,7% dos casos. Em sua maioria, a artéria subclávia direita aberrante não apresenta sintomas. Descrevemos essa alteração em uma paciente de 82 anos, hipertensa e assintomática, que havia sido submetida a uma angiotomografia toracoabdominal para a avaliação de uma dissecção crônica tipo III (DeBakey) associada à dilatação de aorta descendente. No achado, a artéria subclávia direita aberrante apresentava percurso retroesofágico associado a um divertículo de Kommerell. Devido à raridade, realizamos revisão bibliográfica integrativa das bases de dados MEDLINE, UpToDate, LILACS, SciELO e Portal CAPES dos últimos 6 anos e discutimos as alterações anatômicas mais frequentes, a sintomatologia e as condutas terapêuticas adotadas.

Thoracic Endovascular Aortic Repair for Aberrant Subclavian Artery and Stanford Type B Aortic Intramural Hematoma

Objectives

To evaluate the in-hospital and later outcomes of thoracic endovascular aortic repair (TEVAR) for type B intramural hematoma (TBIMH) combined with an aberrant subclavian artery (aSCA).

Methods

In the period from January 2014 to December 2020, 12 patients diagnosed with TBIMH combined with aSCA and treated by TEVAR were enrolled in this retrospective cohort study, including 11 patients with the aberrant right subclavian artery (ARSA) and 1 with an aberrant left subclavian artery (ALSA). A handmade fenestrated stent-graft or chimney stent or hybrid repair was performed when the proximal landing zone was not enough.

Results

The mean age of all the patients was 59.2 ± 7.6 years, and 66.7% of patients were men. There were 4 patients with Kommerell's diverticulum (KD). The procedures in all 12 patients were technically successful. There was one case each of postoperative delirium, renal impairment, and type IV endoleak after TEVAR. During follow-up, 1 patient died of acute pancreatitis 7 months after TEVAR. The overall survival at 1, 3, and 5 years for the patients was 90.9, 90.9, and 90.9%, respectively. KD was excluded in 2 patients, and the handmade fenestrated stent-graft was applied in the other 2 patients to preserve the blood flow of the aSCA. No neurological complications developed and no progression of KD was observed during the follow-up.

Conclusion

Thoracic endovascular aortic repair for patients with aSCA and TBIMH is promising. When KD was combined, we could exclude KD or preserve the blood flow of aSCA with regular follow-up for the diverticulum according to the size of the KD.