1Department or Presentation Title

Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated

with a Type 2 Right-Sided Aortic Arch

Mimmie Kwong, MD

Vascular Surgery PGY-5

U.C. Davis Health

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Normal Arch Development

Left Dorsal AortaRight Dorsal Aorta

Left 4th ArchRight 4th Arch

Left 3rd ArchRight 3rd Arch

Ventral Aorta

Right 7th Intersegmental Artery Left 7th Intersegmental Artery

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Left CCARight CCA

Right SCA Left SCA

Normal Arch Development

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Left Dorsal AortaRight Dorsal Aorta

Left 4th ArchRight 4th Arch

Left 3rd ArchRight 3rd Arch

Ventral Aorta

Right 7th Intersegmental Artery Left 7th Intersegmental Artery

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Left CCARight CCA

Right SCA Left SCA

Right-Sided Aortic Archwith Mirror Image Branching

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Left Dorsal AortaRight Dorsal Aorta

Left 4th ArchRight 4th Arch

Left 3rd ArchRight 3rd Arch

Ventral Aorta

Right 7th Intersegmental Artery Left 7th Intersegmental Artery

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Left CCARight CCA

Right SCA Left SCA

Right-Sided Aortic Archwith Aberrant Left Subclavian

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Epidemiology

• 0.04-0.1% of autopsies 1

• 0.1-0.2% of radiological studies 2

• 40-50% of right sided aortic arches are associated with an aberrant left subclavian artery 3, 4

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Presentation

• Asymptomatic

• Compression of adjacent mediastinal structures• Dysphagia• Stridor• Cough• Dyspnea• Chest pain

• Upper extremity ischemia due to embolization of thrombus

• Aneurysmal degeneration/rupture• High mortality rate ~50% 7

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Treatment

• Open repair:• Left posterior-lateral

thoracotomy• Division and ligation

left subclavian artery at its origin off of the aortic arch

• Patch repair or primary closure of aorta

• Left carotid-subclavian bypass

• Hybrid Repair

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Case Presentation

• 70yo man referred with asymptomatic 4.8cm AAA• COPD, HTN, stable angina, PAD, CKD, active

smoker, asymptomatic carotid stenosis

• Noted on imaging to have “saccular aneurysm in… the origin of the left subclavian artery… in a patient with right-sided aortic arch”

Imaging

6.5 cm

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Operation

• Open:• Left supraclavicular

incision

• Carotid-Subclavian bypass using 8mm ringed PTFE

• 25cm 6Fr retrograde sheath into the L SCA

Operation

• Endovascular:• Percutaneous left

femoral access• 100cm pigtail

• Arch angiogram in multiple obliquities

AP

67 ROA 39 LOA

Operation

• Open right femoral exposure• 0.035 double curved

Lunderquist in to ascending arch

• 34x150 Medtronic Valiant

57 LOA

AP

Operation

• Sheath in L SCA• 10mm Amplatzer II

plug

Follow-up CT Imaging

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Conclusions

• Operative repair for aneurysmal degeneration, dissection, or rupture for Kommerell diverticula associated with right-sided arches has been associated with high mortality rates of 8-17% in the elective setting and 22-100% in the emergent setting 3, 5, 6.

• Hybrid repair is a viable alternative with lower operative risk (7.7% mortality) 7.

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Works Cited

1. A R Hastreiter, I A D'Cruz, T Cantez, E P Namin, and R Licata. Right-sided aorta. Part1: Occurring of right aortic arch in various types of congenital heart disease. Br Heart J. 1966 Nov; 28(6): 722–739.

2. GC Jakanani, W Adair. Frequency of variations in aortic arch anatomy depicted on multidetector CT. Clin Radiol. 2010 Jun;65(6):481-7.

3. CS Cinà, H Althani, J Pasenau, L Abouzahr. Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature. J Vasc Surg. 2004 Jan;39(1):131-9.

4. A Arazińska, M Polguj, K Szymczyk, M Kaczmarska, L Trębiński, L Stefańczyk. Right aortic arch analysis - Anatomical variant or serious vascular defect? BMC Cardiovasc Disord. 2017 Apr 19;17(1):102

5. EH Austin, WG Wolfe. Aneurysm of aberrant subclavian artery with a review of the literature. J Vasc Surg. 1985 Jul;2(4):571-7.

6. JG Barr, AH Sepehripour, OA Jarral, P Tsipas, J Kokotsakis, A Kourliouros, T Athanasioub. A review of the surgical management of right-sided aortic arch aneurysms. Interact Cardiovasc Thorac Surg. 2016 Jul; 23(1): 156–162.

7. C Yang, C Shu, M Li, Q Li, R Kopp. Aberrant subclavian artery pathologies and Kommerell's diverticulum: a review and analysis of published endovascular/hybrid treatment options. J Endovasc Ther. 2012 Jun;19(3):373-82.

1Hybrid Repair of an Aneurysmal Kommerell Diverticulum Associated with a Type 2 Right-Sided Aortic Arch

Images

• V Tatco, Radiopaedia.org, rID: 52192

• KC Hsu, CTC Hsieh, M Chen, and HD Tsai. Right aortic arch with aberrant left subclavian artery—prenatal diagnosis and evaluation of postnatal outcomes: Report of three cases. Taiwan J ObstetGynecol. 2011 Sep;50(3):353-8.

• EY Woo and SM Damrauer (eds.) ExtrathoracicRevascularization (Carotid-Carotid, Carotid-Subclavian Bypass and Transposition). https://basicmedicalkey.com/extrathoracic-revascularization-carotid-carotid-carotid-subclavian-bypass-and-transposition/