Right aberrant subclavian artery with Kommerell's diverticulum, hybrid treatment

Diego Moniaci; Federica Corrado; Franceso Maiorano; Elisa Pagliasso; Tania Peretti

doi:10.4103/2589-9686.376923

CASE REPORT

Year : 2022 | Volume : 5 | Issue : 4 | Page : 116-119

Right aberrant subclavian artery with Kommerell's diverticulum, hybrid treatment

Diego Moniaci, Federica Corrado, Franceso Maiorano, Elisa Pagliasso, Tania Peretti
Department of Vascular and Endovascular Surgery, San Giovanni Bosco Hospital, Torino, Italy

Date of Submission	12-Oct-2022
Date of Decision	02-Feb-2023
Date of Acceptance	06-Feb-2023
Date of Web Publication	15-May-2023

Correspondence Address:
Dr. Diego Moniaci
San Giovanni Bosco Hospital, Torino
Italy

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2589-9686.376923

Abstract

Kommerell's diverticulum (KD) is a diverticular formation of the aortic arch located at the origin of an aberrant subclavian artery (ASA). KD is an extremely rare development abnormality of the aortic arch related to an ASA. KD is also known as “lusoria diverticulum” referring to the aneurysm dilatation of the descending aorta at the origin of ASA. This article reports one case of ASA with KD treated with a hybrid approach endovascular aortic repair with a custom-made endograft (Najuta® endograft) and bilateral axillary–carotid bypass with a 6-mm ePTFE graft. European Society for Vascular Surgery (ESVS) guidelines consider it eligible for treatment KD with a diameter ≥5.5 cm and aneurismatic ASA ≥3 cm. A standardized approach for any KD is unlikely to exist because the better treatment should be individualized and properly applied in an experienced vascular center able to offer all treatment strategies (open, endovascular, or hybrid). To date, the use of new techniques and the development of new materials have made possible ad endovascular approach to ASA with Kommerel's diverticulum.

Keywords: Aberrant, case report, diverticulum, Kommerell, subclavian artery

How to cite this article:
Moniaci D, Corrado F, Maiorano F, Pagliasso E, Peretti T. Right aberrant subclavian artery with Kommerell's diverticulum, hybrid treatment. Vasc Invest Ther 2022;5:116-9

How to cite this URL:
Moniaci D, Corrado F, Maiorano F, Pagliasso E, Peretti T. Right aberrant subclavian artery with Kommerell's diverticulum, hybrid treatment. Vasc Invest Ther [serial online] 2022 [cited 2023 Jun 8];5:116-9. Available from: https://www.vitonline.org/text.asp?2022/5/4/116/376923

Introduction

Kommerell's diverticulum (KD) is a diverticular formation of the aortic arch located at the origin of an aberrant subclavian artery (ASA), described for the first time in 1934 by Dr. Friedrich Kommerell.^[1] KD is an extremely rare development abnormality of the aortic arch related to an ASA. KD is also known as “lusoria diverticulum” referring to the aneurysm dilatation of the descending aorta at the origin of ASA.^[2] Usually, the right subclavian artery (SA) comes from the brachiocephalic artery but it may arise directly from the aortic arch distal to the left SA in 0.4%–1.8% of the general population.^[3]

Aberrant SA with KD often has compression symptoms (dysphagia, dyspnea, coughing, chest pain, rupture, and upper extremity ischemia). Most of these aortic abnormalities are discovered incidentally on computed tomography (CT) scans performed for other reasons. Due to rare presentation, the natural course of the disease is not well understood. Aneurysm rupture has been reported in 53% and aortic dissection in 19%.^[4]

This report describes a case of ASA with KD treated with a hybrid approach endovascular aortic repair with a custom-made endograft and bilateral axillary–carotid bypass.

Case Report

A 71-year-old female came to our attention for an occasional finding of KD in lusory right SA at a staging CT for lung cancer. The patient was asymptomatic for compression symptoms. Her medical history showed hypertension, dyslipidemia, hypothyroidism, hepatitis B virus postemotransfusion, appendicectomy, cholecystectomy, and tonsillectomy.

The chest X-ray showed the aortic arch and a second left subclavian arrow [Figure 1].

Figure 1: Chest X-ray

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The patient underwent chest CT angiography with the evidence of a right SA aneurysm (diameter of 42 mm × 32 mm) partially thrombosed. The left carotid artery originates from the brachiocephalic artery (bovine trunk); the left SA and the other part of the thoracic aorta were regular in morphology. The right SA was patent and directly originated from the aortic arch. In the apical segment of the right upper lobe was possible to note an evolutionary bronchogenic lesion (maximum diameter: 28 mm) connected to the apical pleura [Figure 2]a and [Figure 2]b.

Figure 2: (a) Preoperative CT (CT scan) showing KD. (b) Preoperative CT (CT scan) 3D showing Bovin Vessel and ASA with KD. KD: Kommerell's diverticulum, ASA: Aberrant subclavian artery, CT: Computed tomography

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Preoperative investigations, as chest X-ray and thoracoabdominale CT, were performed.

In this patient, total open vascular surgery was not considered because of high surgical risk and comorbidities.

We decided to proceed with a hybrid approach. The procedure was executed in general anesthesia and monitored with intraoperative electroencephalography.

The patient underwent left axillary–carotid bypass with a 6 mm ePTFE graft and a subsequent right axillary–carotid bypass with a 6-mm ePTFE graft. Endovascular aortic was performed with a custom-made endograft (Najuta® endograft V38) with a single fenestration at the level of the brachiocephalic trunk, to cover the origin of the KD. Embolization of the aneurysm sac (Penumbra Ruby® Coil n°2 32 mm × 60 cm, n°1 28 mm × 60 cm) and the right and left SA were made with coil (Penumbra Ruby® Coil n°1 18 × 60 mm, respectively) [Figure 3].

Figure 3: Najuta® endograft in progress V38

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The patient was monitored with intraoperative electroencephalography, in general anesthesia.

Postoperative recovery was free from complications without adverse events.

Postoperative CT angiography showed a regular position of the endoprosthesis. The bilateral axillary–carotid bypass is well functioning, and the aneurysm sac and right SA are correctly embolized with no endoleaks [Figure 4].

Figure 4: (a) Postoperative CT scan: Aneurysm sac of Kommerel's diverticulum with spirals (Penumbra Ruby® Coil n°2 32 mm × 60 cm, n°1 28 mm × 60 cm). (b) Postoperative CT scan: Bilateral carotid bypass with a 6 mm ePTFE graft and custom-made endograft Najuta®. CT: Computed tomography

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The patient was discharged in the 12^th postoperative day.

Discussion

KD is a congenital anomaly of the aortic arch that arises from failed involution in the fourth primitive dorsal arch. Approximately, KD is present in 20%–60% of cases of ASA. The complications associated with KD are diverticular rupture (4%), aortic dissection (11%), and aortic aneurysm or ASA aneurysm rupture.^[5]

KD has a female predominance with a growth rate of 1.45 ± 0.39 mm/years.^[6]

ESVS guidelines are considered eligible for treatment KD with a diameter ≥5.5 cm and aneurismatic ASA ≥3 cm.

A KD with only ASA is not an indication for invasive treatment and can be treated conservatively. Conservative management is appropriate for asymptomatic patients with ASA without a KD, the presence of symptoms or aneurysm degeneration should be treated immediately.^[4]

The surgical repair options of the right ASA include left thoracotomy with side clamping and repair oversewing the origin of the right SA plus carotid subclavian bypass/interposition, or median sternotomy with the reconstruction of the right SA using a tube bypass from the ascending aorta, or aortic repair with interposition graft.^[6],[7] Surgical procedures can be more required in patients with multiple comorbidities with large diverticula or a greatly dilated aorta.

An endovascular repair is an alternative approach to surgical repair with supposed fewer complications. The endovascular options could be thoracic endovascular aortic repair (TEVAR) or endovascular ASA repair with stent graft.

Andersen et al.^[8] described 31 patients undergone open repair and 12 patients endovascular repair. All asymptomatic patients with compressive symptoms underwent open repair while asymptomatic or those presenting in emergency underwent endovascular repair. Mid-term morbidity was higher in the endovascular group with two patients having a stroke.^[8] There were no statistically differences in other postoperative complications or hospital length of stay between the two groups.^[8]

The hybrid approach, with different techniques, may include a larger number of elective treatments with morphologic anomalies and today it is suggested as the best strategy management of the right ASA.^[8],[9] There are different hybrid approaches such as aberrant right SA transposition or bypassing as the first step and then hemi or complete aortic arch debranching or TEVAR with fenestration or branch.^[10]

Conclusions

Aberrant SA with KD is a rare condition, 0.4%–1.8% of the general population, but ASA with aneurysm rupture has been reported to be 53%.^[3],[4]

A standardized approach for any KD is unlikely to exist because the better treatment should be individualized and properly applied in an experienced vascular center able to offer all treatment strategies (open, endovascular, or hybrid). To date, the use of new techniques and the development of new materials have made possible ad endovascular approach to KD.

Our team has chosen, with good success, a less invasive hybrid approach according to the patient's comorbidities and to the future thoracic surgery for lung cancer.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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