Combined endovascular and aortic arch debranching for the surgical treatment of Kommerell's diverticulum

Background: Kommerell's diverticulum's (KD) (aberrant right subclavian artery aneurysm) is a rare congenital anomaly. Patients with a KD may present with esophageal compression (dysphagia of lysoria), dyspnea and coughing from tracheal compression, chest pain from aneurysm expansion or rupture, or right upper extremity ischemia from thromboembolism. Traditional surgical treatment involves thoracotomy or median sternotomy with aneurysm exclusion and subclavian artery revascularization. However, these techniques increase the surgical morbidities associated with arch cross clamping, hypothermic arrest and cardiac bypass. With the emerging use of thoracic endografting, combined aortic debranching with endovascular exclusion of the aneurysm has now become a contemporary treatment option. We present our experience for repairing Kommerell's diverticulum with this multidisciplinary approach.
Methods: Since January 2006, three patients presented to our university-based vascular surgery service with dysphasia secondary to KD. Mean age was 73 years (range 68 - 76) with two female patients and one male. All patients received pre-operative CT angiography with three-dimensional reconstruction to plan their operative strategies. Operative procedures were completed in a two-staged protocol with aortic arch debranching performed first followed by thoracic endograft placement when clinically stable. Post-operatively, patients underwent CTA to confirm proper positioning of the thoracic graft and patency of the great vessels.
Results: All patients underwent successful exclusion of KD. Mean treatment aneurysm size was 4.8 cm (range 4.2-6.0cm). Mean hospital length of stay was seven days. Surgical debranching techniques included one carotid-carotid-subclavian bypass with bilateral carotid-subclavian bypasses; one bilateral subclavian-carotid transpositions and one subclavian-carotid bypass with contra-lateral subclavian-carotid transposition. Iliac conduits were used in 2 patients to facilitate arterial access and TAG delivery. Successful TAG thoracic exclusion of the aberrant right subclavian aneurysm was accomplished in all patients. One patient had intra-operative proximal stent migration which was successfully repaired with a second TAG device without post-operative morbidity. A second patient had a type II endoleak which was embolized via a brachial artery approach on POD #5 without further complications. Mean follow-up at 10 months (range 3- 16) demonstrates aneurysm exclusion with neither endoleak, neurological and vascular ischemic events nor mortality.Conclusion: Debranching of the great vessels followed by thoracic endograft placement is an effective alternative hybrid procedure for the treatment of KD and possibly other anomalies of the aortic arch.