Two-Stage Hybrid Repair in a Patient with Acute Type A Aortic Dissection Associated with Right Aortic Arch with Aberrant Left Subclavian Artery Originating from a Kommerell Diverticulum

Abstract

Right aortic arch with aberrant left subclavian artery and Kommerell diverticulum are rare anomalies. A 42-year-old man was referred with sudden-onset chest pain. Enhanced computed tomography (CT) showed a right aortic arch with early thrombosed acute type A aortic dissection and an aberrant left subclavian artery arising from a Kommerell diverticulum. Medical therapy was instituted; however, follow-up CT revealed an ulcer-like projection. The patient was managed with a twostage hybrid procedure comprising total arch replacement and endovascular repair and experienced no postoperative complications. Two-stage hybrid repair is a safe and effective surgical option for rare complex aortic anomalies.Keywords: two-stage hybrid repair, right aortic arch with aberrant left subclavian artery, Kommerell diverticulum management is critical for preventing fatal complications. Open-graft replacement with or without the reconstruction of the aberrant subclavian artery has been the standard procedure; however, hybrid surgical/endovascular repair has been recently reported. 2) We report on a patient with a right aortic arch with aberrant left subclavian artery originating from a Kommerell diverticulum complicated by acute type A aortic dissection in whom successful twostage hybrid total arch replacement and thoracic endovascular aortic repair (TEVAR) were performed. Case ReportA 42-year-old man with a history of hypertension and hyperlipidemia was taken by ambulance to our emergency department with sudden-onset chest and back pain. His blood pressure was 134/87 mmHg, and his heart rate was 80 bpm and regular. He was alert and moving all extremities. An electrocardiogram showed normal sinus rhythm with no ST-T segment change. Transthoracic echocardiography revealed normal left ventricular contraction and no valvular disease or pericardial effusion. Contrast-enhanced computed tomography (CT) showed early thrombosed acute type A aortic dissection between the right-sided ascending aorta and the abdominal aorta (Fig. 1A). The aortic dissection involved the wall of the Kommerell diverticulum. The aortic arch was routed from the tracheal and the esophageal right side to the posterior side of the trachea and the esophagus. Three-dimensional CT (3D-CT) demonstrated a right aortic arch with aberrant left subclavian artery arising from a 7-cm Kommerell diverticulum (Fig. 1B). The right and left common carotid arteries arose from the anterior portion of the arch; the right subclavian artery arose more posteriorly from a dilated section of the arch, and the aberrant left subclavian from the large leftsided Kommerell diverticulum. No vascular compression of the esophagus or trachea was noted nor was the artery of Adamkiewicz visible. Thus, the diagnosis was a right

A Rare Case of Submassive Pulmonary Embolism with a Right Aberrant Subclavian Artery and Thrombosed Kommerell Diverticulum

“…To our knowledge, this is the first report on the effect of anticoagulant treatment for a thrombosed KD. Because of the risk of aortic dissection and rupture associated with KD, surgical resection may be advisable (3)(4)(5). If patients do not agree to surgical resection, strict treatment of hypertension and regular CT examinations are indicated.…”

Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear

“…Finally, if the initial operation is a proximal repair into Ishimaru zone 2, the sizing considerations for TEVAR at the proximal landing zone can then be simplified by landing the stent graft into a Dacron aortic graft. 22…”