Transcript Kommerell`s Diverticulum Repair with Right Sided Aortic Arch

Kommerell’s Diverticulum Repair
with a Right-Sided Aortic Arch:
Strategies and Techniques
Phillip D. Smith, MD
Cardiac Surgery Research Fellow
Cardiothoracic Surgery
University of Colorado
Wilson Y. Szeto, MD
Assistant Professor, Cardiovascular Surgery
University of Pennsylvania
T. Brett Reece, MD
Assistant Professor, Cardiothoracic Surgery
University of Colorado
Background
• Kommerell’s Diverticulum
– Congenital diverticulum of a
subclavian artery associated
with various aortic
pathologies and aberrant
subclavian anatomy
• Right sided Aortic Arch
– Two types
• Felson and Palayew Type 1mirror image anatomy of the
great vessels
• Felson and Palayew Type 2aberrant left subclavian
Backer, CL. Eur J Cardiothorac Surg
2002;22:64-69
Case Report
• Three patients with a right-sided aortic
arch and Kommerell’s diverticulum of an
aberrant left subclavian artery
– All greater than 4 cm in maximum diameter
– Two males in their fifties presenting with
dysphagia
– One 36 year old female presenting with
dyspnea secondary to tracheal compression
• All healthy, no significant past medical
history
Representative 3D CTA showing Kommerell’s
diverticulum and aberrant left subclavian
artery
Sagittal view showing
compression of the trachea
by the arch and aberrant
subclavian artery
Goals of Operation
• Eliminate risk of rupture and/or dissection
• Relief of symptoms, while desired, should
not be expected
– Patients should understand that symptoms
may not be ameliorated after procedure
– May be accomplished with resection or
exclusion of the diverticulum
Potential Operative Approaches
• TEVAR exclusion
– Revascularization of the aberrant subclavian artery
– Isolation of diverticulum from blood flow
• Left Thoractomy
– Easier to address distal aberrant subclavian artery
– Descending aortic exposure difficult
• Right Thoracotomy
– Subclavian artery revascularization +/- ligation of proximal
subclavian artery
– Most direct approach to right sided descending aorta
• Left Heart Bypass versus Full Heart Bypass versus
HCA
– Depends on exposure for arch cross clamp
Our Operative Approach
• Two Stage Procedure
– I: Subclavian revascularization via proximal
ligation and transposition
– II: Descending thoracic aortic reconstruction
• Using CPB or HCA
• Diverticulum resection
Reasoning for this Technique
• Definitive treatment of diverticulum by
resection
• Inadequate landing zone in these cases
due to proximity of brachiocephalic
vessels and extreme angulation of distal
arch
• Potential use of HCA as aortic tissue
around the diverticulum is extremely
friable
Outcomes
• Postoperative CT
reconstruction showing
resected diverticula and flow
to the left subclavian via the
transposition graft
• Both cases of dysphagia were
completely resolved at one
year
• Tracheal compression much
improved in dyspneic patient
with improved DOE
Left: Sagittal CT showing resolution of tracheal compresion
Top Right: Posterior 3D CTA reconstruction showing resected
diverticulum and subclavian transposition with flow
Bottom Right: Anterior 3D CTA showing flow in left subclavian after transposition
Key Points
Goals of treatment are prevention of aortic
catastrophe, not treatment of symptoms
While minimally invasive approaches are
feasible, this series demonstrates that a
staged open approach is safe and may
provide symptomatic relief in addition to
aortic protection
Conclusion
A staged open approach to Kommerell’s
Diverticulum resection can be safely
performed with minimal morbidity and
potential symptomatic relief