Two-Stage Hybrid Repair of Kommerell Diverticulum with Supra-Aortic Debranching

Abstract

Objectives The surgical treatment of Kommerell diverticula is associated with high mortality and morbidity rates. In the mid-2000s, hybrid aortic arch repair was developed, and the procedure has since been used to repair Kommerell diverticula. In the present study, we focused on the postoperative outcomes of two-stage hybrid repair of Kommerell diverticula that required supra-aortic debranching (type I hybrid arch repair).

Methods From August 2010 to July 2013, a total of four patients (aged 73.5 ± 9.5 years) underwent two-stage hybrid repair (type I hybrid arch repair) for Kommerell diverticula, and their cases were retrospectively studied. All four patients had right aortic arches and aberrant left subclavian arteries. The repair procedure consisted of two stages: (1) debranching of the supra-aortic vessels via a median sternotomy; (2) exclusion of the Kommerell diverticulum by performing thoracic endovascular repair via a femoral approach and coil embolization of the orifice of the aberrant subclavian artery.

Results There were no in-hospital deaths. One patient developed an acute kidney injury and required hemodialysis on postoperative day 2, although his renal function recovered within 48 hours. No strokes, paraplegia, or early aortic events were observed in our series. The mean follow-up period was 19.5 months (range, 5–47 months). All patients remained free from aortic events and endoleaks during the follow-up period.

Conclusion The early and mid-term outcomes of hybrid repair for Kommerell diverticula that require supra-aortic debranching, which are less invasive and do not involve hypothermic circulatory arrest, are acceptable. However, this procedure requires the insertion of an endograft into the ascending aorta, and careful and long-term follow-up is required to confirm its efficacy.

Keywords

Kommerell diverticulum - thoracic endovascular aortic repair - hybrid arch repair

• References

• 1 Kommerell B. Verlagengerung des Osophagus durch eine abnorm verlaufende Arteria subclavia dextra (Arteria lusoria). Fortschr Geb Roentgenstrahlen. 1936; 54: 590-595
• 2 Freed K, Low VHS. The aberrant subclavian artery. AJR Am J Roentgenol 1997; 168 (2) 481-484
• 3 Cinà CS, Althani H, Pasenau J, Abouzahr L. Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature. J Vasc Surg 2004; 39 (1) 131-139
• 4 Austin EH, Wolfe WG. Aneurysm of aberrant subclavian artery with a review of the literature. J Vasc Surg 1985; 2 (4) 571-577
• 5 Ota T, Okada K, Takanashi S, Yamamoto S, Okita Y. Surgical treatment for Kommerell's diverticulum. J Thorac Cardiovasc Surg 2006; 131 (3) 574-578
• 6 Kouchoukos NT, Masetti P. Aberrant subclavian artery and Kommerell aneurysm: surgical treatment with a standard approach. J Thorac Cardiovasc Surg 2007; 133 (4) 888-892
• 7 Kai M, Okabayashi H, Soga Y , et al. Total arch replacement through a midsternotomy for a right-sided aortic arch aneurysm with an aberrant left subclavian artery. J Thorac Cardiovasc Surg 2006; 132 (6) 1473-1475
• 8 Tsukui H, Aomi S, Yamazaki K. Surgical strategy for Kommerell's diverticulum: Total arch replacement. J Thorac Cardiovasc Surg 2014; 148 (4) 1423-1427
• 9 Corral JS, Zúñiga CG, Sánchez 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 (6) 789-792
• 10 Naoum JJ, Parenti JL, LeMaire SA, Coselli JS. Endovascular repair of a right-sided descending thoracic aortic aneurysm with a right-sided aortic arch and aberrant left subclavian artery. Ann Thorac Surg 2008; 85 (3) 1074-1076
• 11 Kawajiri H, Shimizu H, Yoshitake A, Yozu R. Hybrid repair of a Kommerell diverticulum associated with a right aortic arch and a left descending aorta. J Vasc Surg 2012; 56 (6) 1727-1730
• 12 Idrees J, Keshavamurthy S, Subramanian S, Clair DG, Svensson LG, Roselli EE. Hybrid repair of Kommerell diverticulum. J Thorac Cardiovasc Surg 2014; 147 (3) 973-976
• 13 Yokoi Y, Azuma T, Yamazaki K. Advantage of a precurved fenestrated endograft for aortic arch disease: simplified arch aneurysm treatment in Japan 2010 and 2011. J Thorac Cardiovasc Surg 2013; 145 (3) S103-S109
• 14 Kawajiri H, Oka K, Kanda K, Yaku H. Two-stage hybrid repair for a Kommerell diverticulum in a right-sided aortic arch associated with multivessel coronary disease and atrial septal defect. J Thorac Cardiovasc Surg 2014; 147 (1) 532-534
• 15 Bavaria J, Vallabhajosyula P, Moeller P, Szeto W, Desai N, Pochettino A. Hybrid approaches in the treatment of aortic arch aneurysms: postoperative and midterm outcomes. J Thorac Cardiovasc Surg 2013; 145 (3) S85-S90
• 16 Vallabhajosyula P, Szeto W, Desai N, Bavaria JE. Type I and type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis. Ann Cardiothorac Surg 2013; 2 (3) 280-287
• 17 Williams JB, Andersen ND, Bhattacharya SD , et al. Retrograde ascending aortic dissection as an early complication of thoracic endovascular aortic repair. J Vasc Surg 2012; 55 (5) 1255-1262
• 18 Luehr M, Etz CD, Lehmkuhl L , et al. Surgical management of delayed retrograde type A aortic dissection following complete supra-aortic de-branching and stent-grafting of the transverse arch. Eur J Cardiothorac Surg 2013; 44 (5) 958-963
• 19 Canaud L, Ozdemir BA, Patterson BO, Holt PJ, Loftus IM, Thompson MM. Retrograde aortic dissection after thoracic endovascular aortic repair. Ann Surg 2014; 260 (2) 389-395
• 20 Canaud L, Alric P, Desgranges P, Marzelle J, Marty-Ané C, Becquemin JP. Factors favoring stent-graft collapse after thoracic endovascular aortic repair. J Thorac Cardiovasc Surg 2010; 139 (5) 1153-1157