Complex Hybrid Repair of a Large Descending Thoracic Aortic Aneurysm with Concomitant Diverticulum of Kommerell and Chronic Type B Aortic Dissection
P. Andrew Rivera, Samuel R Money, W.C. Sternbergh, III, Clayton J Brinster
Ochsner Health, New Orleans, LA
Background: Aberrant right subclavian artery (ARSA) is the most common aortic arch anomaly but presents in just 0.3-3.0% of the population. Approximately 20-40% of ARSA undergo aneurysmal degeneration to form a Kommerell’s diverticulum (KD) and the coexistence of KD and associated chronic type B aortic dissection (CTBAD) is extraordinarily rare. Sporadic case reports describe treatment with partial or full aortic debranching via bilateral extra-anatomic bypass and endovascular repair, or with open surgical reconstruction requiring median sternotomy and cardiopulmonary bypass. We describe a novel, less-invasive approach to treat a large descending thoracic aortic aneurysm (DTAA) in the setting of CTBAD and KD.
Methods: An 84 year-old woman with COPD presented with CTBAD with associated DTAA measuring 78mm, originating at the ARSA origin and terminating 24mm proximal to the celiac artery (CA). Centerline analysis demonstrated a KD measuring 28mm in diameter arising from the posterior, distal aortic arch 2mm distal to the left subclavian artery (LSA) origin. Figure 1A shows the proximal extent of false lumen perfusion - Figure 1B demonstrates the ARSA (red arrow), KD (small arrow), and proximal CTBAD extent with aneurysmal degeneration (large arrow). Staged, hybrid surgical and endovascular repair with in-situ laser fenestration was planned.
Results: She first underwent uneventful right carotid-subclavian bypass. On post-operative day two, the mid-ARSA was embolized with an occlusive plug - TEVAR with Zone II coverage including the ARSA and LSA origins was then performed with distal extension to just proximal to the CA. Retrograde, in-situ laser fenestration of the endograft was performed at the LSA origin from a left-brachial approach. A balloon-expandable stent was deployed across the fenestration to restore left upper extremity perfusion. Completion angiogram demonstrated no endoleak, brisk bilateral upper extremity perfusion, and no KD perfusion (Figure 2A). The patient recovered uneventfully, and CTA at one month showed sac regression from 78 to 63mm with brisk bilateral upper extremity perfusion and no endoleak (Figure 2B).
Conclusions: Reports of Kommerell’s diverticulum with concomitant chronic type B aortic dissection and degenerative descending thoracic aortic aneurysm are exceedingly rare. Treatment with open surgical repair requiring cardiopulmonary bypass or hybrid approaches that include bilateral surgical arch debranching or median sternotomy with subsequent TEVAR have been described. To our knowledge, this is the first report of in-situ laser fenestration in this unique scenario to maintain LSA perfusion and extend proximal seal in the aortic arch. This less invasive approach obviates the need for further surgical debranching, reducing the associated morbidity found with previously reported techniques and allowing repair in patients with stable but serious comorbidities. 
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