Ann Thorac Surg 2007;84:1736-1738. doi:10.1016/j.athoracsur.2007.05.077
© 2007 The Society of Thoracic Surgeons
Case Reports
Endovascular Treatment of Acute Type B Dissection and Kommerell’s Diverticulum
Attilio Odero, MD,
Antonio Bozzani, MD*,
Stefano Pirrelli, MD
Division of Vascular Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
Accepted for publication May 30, 2007.
* Address correspondence to Dr Bozzani, Division of Vascular Surgery, Foundation I.R.C.C.S Policlinico San Matteo, P.le Golgi, 2, Pavia, 27100, Italy (Email: a.bozzani{at}smatteo.pv.it).
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Abstract
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A 59-year-old man presented with severe hypertension and resistant interscapular pain. Transesophageal echocardiography and computed tomographic angiogram demonstrated acute type B dissection associated with aberrant right subclavian artery with 3.5 cm Kommerell’s diverticulum. Open repair was deemed to be high risk to elevate perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical therapy because of resistant thoracic pain. We did not observe intraoperative or perioperative mortality and right arm ischemia or symptomatic subclavian steal.
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Introduction
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The association of acute type B aortic dissection and aberrant right subclavian artery (ARSA) arising from a left-sided aortic arch (arteria lusoria) is an uncommon disease. Most patients with ARSA are asymptomatic, but the presence of a Kommerell’s diverticulum can cause progressive dysphagia (dysphagia lusoria) [1]. If untreated, it shows an elevated mortality secondary to aortic rupture. We presented a case successfully managed with endoluminal stent grafting.
A 59-year-old man presented with severe hypertension and interscapular pain. Transesophageal echocardiography demonstrated an acute type B dissection with an intimal flap extending into an aberrant right subclavian artery with a 3.5-cm Kommerell’s diverticulum, confirmed with computed tomographic angiogram (Fig 1). The patient did not report a history of dysphagia. Open repair was deemed at high risk either for elevated perioperative mortality and morbidity of this surgical technique. Therefore the patient was managed with an endovascular procedure after 14 days of medical hypothensive therapy due to his resistant thoracic pain.
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Fig 1. Preoperative computed tomographic angiogram shows an acute type B dissection (left) with an intimal flap extending into a Kommerell’s diverticulum (right). (LCA = left carotid artery; LSA = left subclavian artery.)
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Before the procedures the patient signed a written informed consent to an endoluminal stent of the thoracic aorta in accordance with our institutional guidelines. Under general anesthesia at a vascular operative suite equipped with digital subtraction angiography and transesophageal echocardiography, a guidewire was introduced in the right common femoral artery using a 5-French sheath, and subsequently the introducer system of an endograft was advanced under fluoroscopic guidance. A cannulation of the false lumen was obtained from below through the left femoral artery, and a 7-French introducer sheath and a Simmons catheter was placed in the aortic arch through the left omeral artery for angiographic evaluation of the position of the left common carotid artery. The device (Zenith TX2; Cook Inc, Bloomington, IN) was deployed under controlled hypotension distal to the left subclavian but across the right subclavian orifice for good proximal fixation. The completion angiography demonstrated a successful exclusion of the diverticulum and regular vascularization of visceral vessel through the true lumen. A 50 mm Hg pressure gradient was registered between the two arms without signs of ischemia.
Postoperatively the patient’s right arm was easily fatigable with a weak radial pulse with a confirmed a reversal flow in the right vertebral artery. Neurologic symptoms were not observed.
After a follow-up of 12 months, the patient is alive and well without signs of symptomatic subclavian steal, and a computed tomographic scan confirmed satisfactory placement of the aortic stent-graft with exclusion of Kommerell’s diverticulum and thrombosis of the false lumen of dissection (Fig 2).
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Fig 2. Computed tomographic scan (A) at 12 months demonstrated correct placement of aortic stent-graft, (B) exclusion of Kommerell’s diverticulum and (C) thrombosis of the false lumen of dissection.
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Comment
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The first case of ARSA and Kommerell’s diverticulum was described by Bayford in 1794 and Kommerell [1] in 1936, respectively. An ARSA is the fourth most common aortic arch anomaly with an incidence of 0.5% to 2%. However, as Kommerell mentioned originally, the ARSA that occurs in conjunction with a left-sided aortic arch does not always arise from an aortic diverticulum. Aneurysm of an ARSA, which is well known for early rupture, is an occasional indication for intervention. The various surgical techniques were applied; however a specific strategy for surgical treatment of Kommerell’s diverticulum has not yet been established. Surgical mortality used to be as high as 16.6%, except for rupture. Moreover the association with acute type B dissection is extremely rare. Patients with life-threatening complications of acute dissection of the descending aorta are therapeutically more challenging. The indications for intervention in acute type B aortic dissections have historically included rupture and resistant pain or hyperthension, distal ischemia, and degeneration of the aortic wall causing aneurysm formation. So far the only effective treatment option was open emergency surgical intervention with replacement of the descending aorta. Early mortality used to be very high (greater than 50%). Although the mortality has been reduced in recent years to 21% to 40%, there is still a significant morbidity and mortality after surgical repair of complicated acute type B aortic dissections. For this high-risk group of patients, a safer and equally effective form of treatment is desirable. The endovascular treatment of thoracic aortic pathology is feasible and less invasive [2]. This shows that with a lot of expertise there is a potential for very low mortality after emergency stent grafting, even in patients with complicated acute type B aortic dissections.
If the proximal landing zone for the thoracic stent-graft is proximal to the origin of the left subclavian artery, the combined (surgical and endovascular) procedure is necessary for supraaortic trunk revascularization, but our experience supports expectant treatment of subclavian steal from intentional occlusion of the subclavian artery. We believe that the auxiliary surgical revascularization should be reserved for those patients who develop ischemic symptoms or who have a potentially compromised collateral arm supply (previous aortocoronary bypass surgery with use of the left internal mammary artery, critically stenosed carotid or vertebral arteries, or both, or a functionally compromised circle of Willis).
To date, four cases of combined treatment [3–6] and a single case of endovascular treatment of an ARSA aneurysm were reported [7]. We believe that this is the first report of a stent-graft of an acute type B aortic dissection with involvement of an ARSA aneurysm [8], and our case shows that endovascular treatment of this pathology is feasible and safe.
In conclusion, an endovascular stent-graft provides a safe and reliable tool complementing the armament of surgical techniques in the treatment of patients with acute type B dissection with ARSA associated with Kommerell’s diverticulum, although additional experience is mandatory before this technique can prove to be effective.
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References
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- Kommerell B. Verlagerung des Ösophagus durch eine abnorm verlaufende subclavia dextra (Arteria lusoria) Fortschr Geb Roentgenstrahlen 1936;54:590-595.
- Nienaber CA, Ince H, Weber F, et al. Emergency stent-graft placement in thoracic aortic dissection and evolving rupture J Card Surg 2003;18:464-470.[Medline]
- Lacroix V, Astarci P, Philippe D, et al. Endovascular treatment of an aneurysmal aberrant right subclavian artery J Endovasc Ther 2003;10:190-194.[Medline]
- Corral JS, Zuniga CG, Sanchez JB, Guaita JO, Basail AM, Gimeno CC. Treatment of aberrant right subclavian artery aneurysm with endovascular exclusion and adjunctive surgical bypass J Vasc Interv Radiol 2003;14:789-792.[Medline]
- Attmann T, Brandt M, Müller-Hülsbeck S, Cremer J. Two-stage surgical and endovascular treatment of an aneurysmal aberrant right subclavian (Lusoria) artery Eur J Cardiothorac Surg 2005;27:1125-1127.[Abstract/Free Full Text]
- Myamoto S, Hadama T, Anai H, et al. Successful open stent grafting of a right aortic arch and a descending aortic aneurysm originating from a Kommerell’s diverticulum: report of a case Surg Today 2002;32:359-361.[Medline]
- Hutton M, Wolf B, Boyne N, Tripathi R, Sieunarine K. A case report of intentional occlusion of an aberrant right subclavian artery during endovascular stent-graft repair of a descending aortic aneurysm Eur J Vasc Endovasc Surg 2004;27:222-224.[Medline]
- Dhareshwar J, Estrera AL, Porat EE, Azizzadeh A, Safi HJ. Acute type B dissection with involvement of an aberrant right subclavian artery: an unusual presentation and a diagnostic challenge J Cardiovasc Surg 2006;132:689.
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Abstract
Introduction
