Combined endovascular and surgical (hybrid) repair of type B aortic dissection with aneurysmal degeneration involving Kommerell's diverticulum and aberrant right subclavian artery

Abstract

A 44-year-old woman presented with a 3-year history of type B aortic dissection. A computerized tomographic scan revealed a type B aortic dissection with a 4.1-cm proximal descending thoracic aneurysm involving a Kommerell’s diverticulum with an aberrant right subclavian artery. Eleven months later, the aneurysm had enlarged to 6 cm (Cover, posterior view; A, anterior view). The patient had intermittent chest pain, dysphagia, and left upper-extremity swelling secondary to innominate vein compression. A two-stage hybrid approach was recommended. The first stage consisted of a right carotid subclavian bypass with endovascular occlusion of the aberrant right subclavian artery and a left carotid subclavian bypass. Two months later, the repair was completed with a proximal ascending aorta-to-right common carotid and left common carotid bypass through a median sternotomy (B) and endovascular repair of the distal aortic arch and proximal thoracic aneurysm with an endovascular graft originating in the distal ascending aorta. Two years later, the patient is asymptomatic with good blood pressure control and normal kidney function, and the left arm swelling has resolved. On follow-up computerized tomographic scan, the proximal descending aneurysm has decreased to 5.2 cm, with no endoleak, and stable distal aortic dissection (C). Aberrant right subclavian artery is the most common aortic arch anomaly. Endovascular and hybrid repairs of aneurysmal degeneration of Kommerell’s diverticulum, the anomalous artery, and/or the aorta have been reported. When aneurysmal degeneration of the anomalous right subclavian artery occurs, a concomitant abdominal aortic aneurysm is present in 25% of cases. Type B aortic dissection in the presence of an anomalous right subclavian artery with Kommerell’s diverticulum is rare. A single case has been reported using extra-anatomic bypasses for the subclavian arteries and an endovascular graft distal to the left common carotid. The case herein reported is the first report of complete arch debranching for hybrid repair of a type B aortic dissection with aneurysmal degeneration in the presence of an anomalous right subclavian artery with a Kommerell’s diverticulum.