Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature

We report four consecutive cases of Kommerell's aneurysm of an aberrant left subclavian artery in patients with a right-sided aortic arch and the results of a systematic review of the literature. In our cohort of patients, three had an aneurysm limited to the origin of the aberrant subclavian artery, causing dysphagia and cough, and one had an aneurysm involving also the distal arch and the entire descending thoracic aorta, causing compression of the right main-stem bronchus. A left subclavian-to-carotid transposition was performed in association with the intrathoracic procedure, and a right thoracotomy was used in all patients. One of the patients underwent surgery with deep hypothermia and circulatory arrest, and the others with the adjunct of a left-heart bypass. The repair was accomplished with an interposition graft in two patients and with endoaneurysmorrhaphy in the others. The postoperative course was complicated by respiratory failure and prolonged ventilation in one patient, and one patient died because of severe pulmonary emboli. The survivors are alive and well at a follow-up of 1 to 3 years. Only 32 cases of right-sided aortic arch with an aneurysm of the aberrant subclavian artery have been reported: 12 were associated with aortic dissection, and 2 presented with rupture. Surgical repair was accomplished in 29 patients. A number of operative strategies were described: right thoracotomy, bilateral thoracotomy, left thoracotomy with sternotomy, sternotomy with right thoracotomy, and left thoracotomy. In only 12 cases was the subclavian artery reconstructed. We believe that a right thoracotomy provides good exposure and avoids the morbidity associated with bilateral thoracotomy or sternotomy and thoracotomy. We feel that a left subclavian-to-carotid transposition completed before the thoracic approach revascularizes the subclavian distribution without increasing the complexity of the intrathoracic procedure.     

Surgery of the dissecting aneurysm involving a right aortic arch

A dissecting aneurysm in association with a right aortic arch is extremely rare. However, a 50-year-old male was diagnosed as having a dissecting aneurysm (DeBakey IIIa) with a right aortic arch, right descending aorta and an aberrant retro-esophageal left subclavian artery. A graft replacement of the right descending aorta was successfully performed under right thoracotomy and partial cardiopulmonary bypass. Precise anatomical definition and proper surgical procedure permitted a successful surgical result.     

A successful surgical case of DeBakey IIIb dissecting aortic aneurysm in association with right aortic arch

A case of chronic DeBakey IIIb dissecting aneurysm in association with right aortic arch is reported. A 49-year-old man having encountered an aortic dissecting episode two years ago, was examined more closely because the aneurysm became larger recently. Digital subtraction angiography (intra-venous and intra-aortic) showed DeBakey IIIb dissecting aneurysm associated with a right aortic arch with aberrant subclavian artery. The entry of the aneurysm was in the right descending aorta passing from left thorax to right. The operative indication was for enlarged false lumen in this case. Graft replacement of the aneurysm and closure of the false lumen in the right thorax was performed under partial cardiopulmonary bypass through right thoracotomy. Postoperative digital subtraction angiography showed that dissection was in the abdominal aorta but false lumen in the thorax was completely closed. The patient has made a comeback working. A case of dissecting aortic aneurysm associated with right aortic arch is extremely rare. To our knowledge, this is the third such case reported in Japan, but the first case of a successful graft replacement for dissecting aortic aneurysm associated with right aortic arch.     

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.     

Surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery

A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell's diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.     

Surgical repair of left-sided cervical aortic arch aneurysm: case report and literature review

Cervical aortic arch (CAA) is a rare vascular malformation which sometimes accompanies other cardiovascular malformations. Surgical approaches such as a lateral thoracotomy and a median sternotomy are selected depending on the position and type of aneurysm and other associated malformations. We herein report the case of a CAA patient who was a 38-year-old female and demonstrated an aneurysm between the left common carotid artery and left subclavian artery in addition to the persistence of the left superior vena cava (PLSVC). During surgery, the aortic arch from the distal right brachiocephalic trunk bifurcation to the proximal left subclavian artery bifurcation was replaced with a prosthetic graft to reconstruct the left common carotid artery. The median sternotomy approach was selected. Hypothermic circulatory arrest was performed using a cardiopulmonary bypass (CPB), and anterograde cerebral perfusion was conducted from the brachiocephalic trunk. The patient was discharged from the hospital without any complications 16 days after surgery. Magnetic resonance angiography was useful for diagnosing the precise position of the aneurysm. When encountering an aneurysm associated with the CAA in the transverse aortic arch or PLSVC, the median sternotomy approach is considered the treatment of choice.     

A left subclavian arterial aneurysm ruptured into the left lung--a case report]

A 68-year-old man complained bloody sputum. Angiography revealed the left subclavian arterial aneurysm that was arising from the origin of the left subclavian artery. The aneurysm was resected with the adhesive lung tissue through a left posterolateral thoracotomy in the third intercostal space, and an 8 mm EPTFE graft was implanted between the aortic arch and the left subclavian artery. The aneurysm was filled with old thrombus and it was ruptured into the left lung. The pathologic study showed typical atherosclerotic changes. Postoperative course was uneventful, and his bloody sputum disappeared.     

Repair of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum

A case of right aortic arch with an aberrant left subclavian artery arising from a Kommerell's diverticulum of the descending thoracic aorta with a left ligamentum arteriosum completing a vascular ring about the trachea and esophagus is presented. A posterolateral left thoracotomy alone is sufficient to provide an excellent exposure for the division of the ligamentum arteriosum and the resection of the Kommerell's diverticulum. Furthermore, the development of a subclavian steal syndrome is prevented by the reimplantation of the divided left subclavian artery into the left common carotid artery through this same incision.     

A case report of intrathoracic aneurysm of left subclavian artery

A case of intrathoracic aneurysm of the left subclavian artery is reported. The case was 68-year-old male. Chest CT and angiography revealed an aneurysm of left subclavian artery (LSA) located the proximal portion of LSA. The chest was opened by fourth intercostal thoracotomy. We evaluated the intima of distal aortic arch and LSA by introperative direct echography using a small probe (finger tip size). Since there was no calcification or mural thrombi at the distal aortic arch, the aneurysm was resected using partial cardiopulmonary bypass and the orifice of LSA was closed direct suture. LSA was reconstructed with knitted Dacron graft (8 mm). Postoperative course was uneventful.     

Asymptomatic pseudo-aneurysm of the aortic arch in a patient with aberrant right subclavian artery. A complication of Kommerell's diverticulum?

Kommerell's diverticulum is an aortic arch deformity associated with an aberrant subclavian artery. Symptoms related to compression of adjacent structures, dilatation of the aortic diverticulum or accelerated atherosclerosis leading to increased risks of dissection and rupture represent the indications for surgical treatment. Several surgical strategies have been used for the management of this congenital abnormality. We present the case of a 56-year-old male with a pseudo-aneurysm of a left aortic arch adjacent to a Kommerell's diverticulum at the orifice of a left subclavian artery. The patient also presented an aberrant right subclavian artery originating from the posterior wall of the ecstatic take-off of the left subclavian artery. Our surgical strategy was limited to the resection of the aneurysm without any manipulation of the aortic diverticulum and aberrant right subclavian artery, as the wall of both aorta adjacent to the saccular aneurysm and left subclavian artery was normal, the Kommerell's diverticulum was small and the patient was asymptomatic.     

Off-pump coronary artery bypass grafting via a left thoracotomy in a patient with left main trunk disease

We report a case of multiple coronary artery bypass grafting (CABG) via a left thoracotomy without cardiopulmonary bypass. A 54-year-old female with unstable angina pectoris associated with left main trunk disease underwent emergency CABG. Because the patient had a history of total arch and aortic root replacement due to type A aortic dissection, a left thoracotomy approach was selected. The proximal end of the Y-shaped saphenous vein graft was anastomosed to the left subclavian artery, rather than to the descending aorta, owing to the remaining aortic dissection. The distal end of the Y-shaped saphenous vein graft was anastomosed to the left anterior descending artery and the posterolateral branch without cardiopulmonary bypass. The postoperative course was uneventful. The results of this surgery seem to indicate that off-pump CABG via a left thoracotomy is a viable technique, especially for patients undergoing repeat CABG.     

Surgical Treatment of Recurrence of an Aneurysm of Aberrant Right Subclavian Artery

A bstract A 52-year-old woman underwent incomplete resection of an aneurysm of the aberrant right subclavian artery. Three years later she was hospitalized because of a right superior mediastinal mass on the chest X-ray and a new angiography revealed dilatation of the remaining part of the aberrrant right subclavian artery near its origin and involving the adjacent thoracic aorta and the distal aortic arch. At surgery, a left posterolateral thoracotomy in the fourth intercostal space was performed. Using deep hypothermia and circulatory arrest the aneurysm was excised and the aortic tract adjacent to the aneurysm was replaced with a Dacron prosthesis.     

An aberrant left subclavian artery aneurysm with right aortic arch: Report of a case

The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.     

Surgical repair for aortic dissection accompanying a right-sided aortic arch

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.     

Novel approaches for the treatment of the aberrant right subclavian artery and its aneurysms

We report a minimally invasive, hybrid endovascular approach that was used to treat two patients with aberrant right subclavian arteries. The first patient was a 50-year-old woman who presented with dysphagia lusoria. She underwent endovascular plugging and depressurization of the aberrant artery and a carotid-subclavian bypass using right supraclavicular access. The second patient, a 77-year-old woman who presented with a 5.5-cm aneurysm at the origin of a previously bypassed aberrant artery on the distal aortic arch, was treated using bilateral carotid-subclavian bypasses through neck incisions and a thoracic endoluminal graft exclusion of the arch aneurysm that covered both subclavian arteries.     

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.     

Aortic coarctation,vascular ring,and right aortic arch with aberrant subclavian artery

Right aortic arch, in all situations, is relatively rare. In association with coarctation and vascular compression, it is extremely rare. We present a patient with a right aortic arch and an aberrant left subclavian artery, in addition to coarctation. This was dealt with through a left thoracotomy by dividing the ligamentum arteriosum and placing a Dacron graft from the ascending aorta to the descending aorta.     

Anomalous vertebral artery origins: the first and second reports of two variants

We present two cases of aberrant origins of vertebral arteries. Case 1 is of a patient undergoing evaluation of an infrarenal aortic aneurysm stent graft. Computed tomography (CT) angiogram revealed an aberrant right vertebral artery that subsequently joined a second right vertebral artery that had the typical origin off the right subclavian artery. This represents an unusual anatomic variation not previously reported in the literature. Case 2 is of a patient being evaluated for thoracic aorta injury. CT angiogram of the chest revealed a five-vessel aortic arch with aberrant origin of the bilateral vertebral arteries distal to the left subclavian artery.     

Surgical repair of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum

Five cases of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum, with or without Kommerell's diverticulum, are presented. Either right or left thoracotomy with divesion of the aberrant retroesophageal left subclavian artery can be accomplished with good results. However, a right thoracotomy is recommended in the presence of a large Kommerell diverticulum because such a diverticulum should be excised. The development of a subclavian steal syndrome later in life may be prevented by reimplantation of the divided left subclavian artery into the aorta or the left common carotid artery.