Open surgical repair of Stanford type A dissection due to Kommerell's diverticulum associated with an aberrant right subclavian artery

Abstract

BackgroundKommerell's diverticulum with Stanford type A aortic dissection is a relatively rare condition. There is currently no standard treatment strategy for Kommerell's diverticulum. We herein report our surgical strategy with a review of literature for a case of Kommerell's diverticulum that developed acute aortic dissection. Case presentationA 54-year-old woman was referred to our hospital after being diagnosed with Stanford type A acute aortic dissection at the hospital where she was admitted for chest and back pain. Contrast-enhanced computed tomography showed a right and left common carotid and left subclavian artery branching from the aortic arch; Kommerell's diverticulum and an aberrant right subclavian artery (RSCA) arising from it were noted in the distal arch. The contralateral aortic wall where Kommerell's diverticulum was located was the entry, resulting in aortic dissection, with retrograde dissection extending into the ascending aorta. Partial thrombosis was detected in the false lumen of the ascending aorta. The dissection extended from the ascending aorta to the common iliac artery. In addition, the thrombosed false lumen in the left common iliac artery was considered to have caused dynamic obstruction due to compression and narrowing of the true lumen. Based on these findings, total arch replacement with reconstruction of the 4-branched vessels in the arch, including an aberrant RSCA, the frozen elephant trunk technique, and femoro-femoral bypass for malperfusion of the left lower extremity were performed with deep hypothermic circulatory arrest. An artificial graft was anastomosed to the right axillary artery, which was used as the blood supply route for cardiopulmonary bypass. After cooling to hypothermia, the central portion of the aberrant right subclavian artery was clipped on the right side of the trachea. Thus, cerebral blood flow was maintained via the right vertebral artery, the aortic arch was opened, and cannulas for selective cerebral perfusion were inserted into the right common carotid artery, the left common carotid artery, and the left subclavian artery. After each vessel was reconstructed, the graft that had been anastomosed to the right axillary artery was anastomosed to the graft used for reconstruction of the right common carotid artery. The patient's postoperative course was generally good. ConclusionThe strategy used by us effectively created transient occlusion of the origin of Kommerell's diverticulum and the primary entry. Our results indicate that this method is feasible and effective for cases in which in situ reconstruction of the branch may be challenging.