Regarding “Kommerell's diverticulum and right-sided aortic arch: a cohort study and review of the literature”

Abstract

We read with interest the recent (J Vasc Surg 2004;39:131-9) and previous1Cinà C.S Arena G Bruin G Clase C.M Kommerell's diverticulum and aneurysmal right-sided aortic arch a case report and review of the literature.J Vasc Surg. 2000; 32: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar reviews by Cinà et al describing the approach to patients with a Kommerell's diverticulum and a right-sided aortic arch. A similar case previously published in the Journal by our group2Donatelli F Pocar M Pelenghi S Moneta A Grossi A Aortic diverticulum without vascular ring a rare cause of dysphagia.J Vasc Surg. 1997; 26: 142-143Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar is cited in the recent article, although some features are not reported while others are outlined incorrectly. Our patient presented with severe dysphagia and milder compression symptoms due to an isolated Kommerell's diverticulum—ie, very unusually, with no vascular ring—and a right-sided aortic arch. The origin of the supra-aortic vessels corresponded to Edward's type I (mirror image). The lesion was diverticular rather than aneurysmal and measured 3 cm in diameter, but extended posteriorly for 6.5 cm between the aorta and the esophagus (not described). Because a true Kommerell's diverticulum in the presence of a right-sided arch represents a remnant of the left dorsal aorta, it can be speculated that, embryologically, the anomaly comprised a right arch with a retroesophageal left ductus arteriosus,3Moes C.A.F Freedom R.M Rings, slings, and other things vascular structures contributing to a neonatal “noose.”.in: Freedom R.M Benson L.N Smallhorn J.F Neonatal heart disease. 1st ed. Springer-Verlag, London1992: 731-750Crossref Google Scholar, 4Hong Y.T Fu Y.C Chen C.H Jan S.L Wang T.M Chang Y et al.Vascular ring due to double aortic arch with atretic left arch and left ligamentum arteriosum report of one case.Acta Paediatr Taiwan. 2003; 44: 168-170PubMed Google Scholar and that progressive closure of the ductus after birth determined an atretic segment—ie, the ligamentum arteriosum proper and the posterior left portion of the vascular ring—along with a Kommerell's diverticulum originating from the aortic isthmus (Fig); differentiation from double aortic arch with left arch atresia distal to the left subclavian artery is virtually impossible although in the latter condition the left innominate artery is tethered caudally and more horizontal. This specific anatomy closely resembles that described by Cinà in Case 1 prior to reoperation, in a patient who underwent previous division of the ligamentum arteriosum and of an aberrant left subclavian artery through the left chest. In our case the diverticulum's root was divided on a side-biting clamp, with no clamp-and-go, avoiding extensive mobilization posterior to the esophagus because of the adhesive and fragile nature of the surrounding tissues. Although this technique has not been previously described, it is worth mentioning that tangential clamping and direct suture was straightforward, probably because, in the absence of an aberrant subclavian artery, the surrounding aorta was relatively normal and non-aneurysmal. We agree that distal perfusion is preferable to a clamp-and-go technique if aortic cross clamping is necessary. The idea of performing left heart bypass with left atrial drainage through the right chest is appealing, and the technique can safely be converted to full cardiopulmonary bypass if required. Except for potential applications of endovascular stent grafting,5Corral J.S Zuniga C.G Sanchez J.B Guaita J.O Basail A.M Gimeno C.C Treatment of aberrant right subclavian artery aneurysm with endovascular exclusion and adjunctive surgical bypass.J Vasc Interv Radiol. 2003; 14: 789-792Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar we concur that a right posterolateral thoracotomy through the 4th intercostal space, with or without rib resection, is the best approach to a right-sided upper descending aorta. We also strongly agree that an aberrant subclavian artery should be transposed and reimplanted or bypassed rather than divided, and that a combined cervical-thoracic strategy is preferable to an extended entirely thoracic approach; in this respect, we would like to stress that we did not perform a sternothoracotomy. Finally, although it refers to a combined cervical-thoracic operation,6Donatelli F Pocar M Pelenghi S Moneta A Grossi A Combined carotid and cardiac procedures improved results and surgical approach.Cardiovasc Surg. 1998; 6: 506-510Crossref PubMed Scopus (15) Google Scholar the article cited in the references is not our previously published paper in this Journal!2Donatelli F Pocar M Pelenghi S Moneta A Grossi A Aortic diverticulum without vascular ring a rare cause of dysphagia.J Vasc Surg. 1997; 26: 142-143Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar ReplyJournal of Vascular SurgeryVol. 39Issue 6Preview Full-Text PDF Open Archive