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3D Printing for Surgical Case Planning in Kommerell Diverticulum
Diana M Otoya1, Sally Boyd1, Daniel H Newton1, Rahul Rajeev1, Brian M Burkhardt2, Michael Amendola2, Vigneshwar Kasirajaan1
1Virginia Commonwealth University Health Systems, Richmond, VA;2Central Virginia Veterans Health Care Systems, Richmond, VA

Objectives: A right-sided aortic arch is a rare congenital defect of the thoracic aorta, with a reported incidence of 0.1%. Symptoms vary depending on the configuration of aortic branches and the presence of a vascular ring, which can result in compression of the esophagus and trachea. Approximately 60% of patients will experience aneurysmal degeneration. Due to the rare incidence of this disorder, a paucity of literature exists on optimal surgical management. 3D printing in preoperative planning can augment surgeons' and trainees' understanding of complex and rare anatomy. The aim of this study was to present a novel application of 3D printing in a complex aortic malformation. Methods: We present the case of a 40-year-old male with a known history of a right-sided aortic arch who presented to the clinic with dysphasia. A swallow study demonstrated a tortuous proximal esophagus due to extrinsic compression from a right-side aortic arch and Kommerell diverticulum. CTA confirmed a right-sided aortic arch with a complete vascular ring resulting from a left-sided ligamentum arteriosum attaching to the pulmonary artery and the Kommerell diverticulum. Given the complex vascular anatomy 3D reconstruction and model were requested. Patients' DICOMs (digital imaging and communications in medicine) were used and segmented using Materialize 3-Matic medical software. Key elements were the aortic arch and vessels, pulmonary artery, ligamentum arteriosum, esophagus, trachea, sternum, clavicle, and 1st rib were included for reference points. The model was printed using a J750 MediJet color printer. Due to his unique anatomy and preference for long-term durability, the patient elected to proceed with open surgical repair. Results: The patient was taken to the operating room, induced under general anesthesia, and intubated using a double-lumen tube. A left posterior lateral thoracotomy incision was made, and the lung was mobilized anteriorly to expose the aorta. Intraoperative, the 3D printed model was referenced for orientation and identification of the ligamentum arteriosum. The diverticulum was large, measuring approximately 3 cm with a large band, the ligamentum arteriosum, compressing the esophagus. An additional thin band was identified from the diverticulum towards the left subclavian artery which was not seen on CT scan due to limitations on scan slice thickness. The band was excised using an Endo GIA™ Stapler. The aneurysm was excised and oversewn and a pleural flap was placed between the aortic suture line and the esophagus to prevent erosion. At the end of the operation, we performed an upper endoscopy, which showed patency of the esophagus. Post-operatively, the patient had ongoing dysphasia and voice hoarseness. Direct laryngoscopy showed left vocal cord paralysis. At 3-month follow-up, the patient had improvement in symptoms. The patient will undergo long-term surveillance for further aneurysmal degeneration of the diverticulum. Conclusion: In conclusion, a right-sided aortic arch is a rare disorder with complex and diverse anatomical variants. The surgical approach depends on the anatomic characteristics of the lesion, patient fitness, and acuity of presentation. 3D printed models can increase understanding of anatomy, improve team communication, and offer intraoperative guidance.
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