Resection Of Kommerell Diverticulum Research Articles

Long-term Outcomes Following Thoracoscopic Division of Vascular Rings

ObjectivesWe evaluate long-term symptomatic improvement in vascular ring patients who underwent thoracoscopic division at a single quaternary pediatric surgery center. MethodsAll pediatric patients who underwent vascular ring division without Kommerell's diverticulum resection between 01/2007–12/2022 were included. Surgeries were performed by pediatric general and thoracic surgeons. Patient demographic and clinical characteristics were obtained from retrospective chart review. Data on long-term symptomatic improvement were collected with structured telephone interviews. Results60% of patients were male. Median age at operation was 24 months (IQR: 11, 60 months) with a median weight of 11.3 kg (IQR: 8.7, 19.8 kg). All patients were symptomatic preoperatively with dysphagia being the most frequent complaint (42%), followed by chronic cough (21%). Of 41 patients eligible for the long-term follow-up survey, 8 patients with a primary diagnosis of a double arch with an atretic segment in the non-dominant arch and 9 with a right dominant arch with left ligamentum arteriosum and aberrant left subclavian artery (LSCA) were contacted and consented for participation. Median interval from surgery to survey completion was 95 months (IQR 28, 135 months). Most patients had no, or only minor, symptoms related to breathing and swallowing at the time of long-term follow-up. 88% of patients experienced postoperative symptom improvement, and only one patient reported worsening of symptoms over time. ConclusionDivision of an atretic arch and/or ligamentum for patients with an aberrant LSCA without Kommerell's resection may be adequate to ensure long-term improvement of breathing and swallowing problems attributable to vascular rings. Level of EvidenceLevel IV.

A Ten-year Single-center Surgical Experience With Symptomatic Complete Vascular Rings

Limited data exist on the management of complete vascular rings (CVR) in adults. We reviewed our institution's surgical experienceinthe managementof these patients. Between 2010 and 2019, all adult patients that underwent a thoracotomy for a CVR repair were identified. We performed a retrospective medical record review of these patients to characterize their demographics and outcomes. Among the 5 patients identified (3 females, 2 males; Mean age 50 ± 9 years), anatomic variants were right arch and Kommerell diverticulum (KD) in 3 (60%) and double aortic arch in 2 (40%) patients. Indications for operation included dysphagia in 4 (80%), respiratory symptoms in 3 (60%) and aneurysmal KD in 1 (20%) patient. Two right aortic arch exclusion, 1 ligamentum arteriosum (LA) division, 1 LA division combined with a KD resection and 2 aortic reconstructions with interposition Dacron graft under partial cardiopulmonary bypass, were performed. Two carotid-subclavian artery transpositions prior to the thoracotomy were done. The postoperative length of stay was 10.0 (IQR 7.3-14.8) days. One reoperation for chylothorax and 1 for symptoms recurrence were performed for the same patient. Over a follow-up period of 1.4 (IQR 0.4-7.0) years, no mortality or majorpostoperative complications occurred. At their last follow-up visit, all patients reported no related remaining symptoms, except for persisting mild asthma in 1 patient. Open repair of CVR in adults can be performed safely with low complication rate. Symptoms improved in all patients after definitive repair.

Translocation of aberrant left subclavian artery and resection of Kommerell diverticulum during the concomitant repair of intracardiac anomalies.

To assess the safety and efficacy of the translocation of the aberrant left subclavian artery (LSCA) and resection of the Kommerell diverticulum during the concomitant repair of intracardiac anomalies for paediatric patients who had a right-sided aortic arch. A retrospective review of paediatric patients who were diagnosed right-sided aortic arch, aberrant LSCA, Kommerell diverticulum and intracardiac anomalies between 2015 and 2019 was conducted. Patients who underwent translocation of the aberrant LSCA, diverticulum resection and concomitant intracardiac repair were included. Eight patients underwent translocation of aberrant LSCA, diverticulum resection, ligamentum division and concomitant repair of the associated intracardiac anomalies. All patients were male. The median age was 1.3 years (range 0.4-5.5 years) and the median weight was 10.0 kg (range 6.1-21.0 kg). The most commonly combined intracardiac anomaly was a ventricular septal defect. Seven patients (87.5%) had preoperative respiratory or gastrointestinal symptoms. There was no early mortality and no postoperative complications. During the median follow-up of 23 months (range 4-43 months), no patient had residual respiratory or gastrointestinal symptoms. A postoperative computed tomography scan was performed in 3 patients, all of which showed patent LSCA-left carotid artery anastomosis. Translocation of the aberrant LSCA and resection of the Kommerell diverticulum can be safely performed during the concomitant repair of intracardiac anomalies for paediatric patients. This approach could eliminate residual respiratory and gastrointestinal symptoms, and prevent reintervention in the future.

Vascular Rings With Tracheoesophageal Compression: Management Considerations.

Our series of vascular ring patients treated at Ann & Robert H. Lurie Children's Hospital of Chicago has now exceeded 450 patients (see Central Picture). The recommendations from this review are based on our experience with those patients. Since 1990, we have used preoperative cross-sectional imaging in all vascular ring patients. This has led us to refine our operative strategies and carefully tailor the operation to the individual's unique anatomy. In particular for right aortic arch patients, we now address the Kommerell diverticulum in most cases and carefully consider Kommerell diverticulum resection with left subclavian artery transfer. In double aortic arch patients, we also look for a Kommerell diverticulum and resect the diverticulum if present. This will decrease the number of patients presenting for a reoperation after initial vascular ring surgery. Since 1947, we have operated on 217 patients with a right aortic arch. The median age is 1.5 years. Since 2006, 47 out of 111 patients have had Kommerell diverticulum resection and left subclavian artery transfer to the left carotid artery. Mean length of stay is 4.5 days. In the same time period, 187 patients have been treated for a double aortic arch. The median age is 1 year. Twelve of these patients also had resection of a Kommerell diverticulum. The mean length of stay in this group was 3 days. Advanced preoperative cross-sectional imaging leads to precise operative techniques tailored to the unique anatomy of each vascular ring patient.

Resection of Kommerell Diverticulum and Reimplantation of Aberrant Left Subclavian Artery in Right Aortic Arch Vascular Ring

A right aortic arch vascular ring consists of an anomalous aortic arch course with a ligamentum arteriosum and an aberrant left subclavian artery arising from a Kommerell diverticulum. Division of the ligamentum arteriosum is required for the relief of symptoms in these patients. However, to prevent recurrent symptoms, resection of the Kommerell diverticulum and reimplantation of the subclavian artery to the left carotid artery is advocated. Here we describe our standardized surgical approach to this pathology.

Invited Commentary

Management of Kommerell’s diverticulum associated with aberrant subclavian artery reconstruction remains controversial, partly because it is such a rare anomaly. Airway compromise is uncommon and typically presents early in life. Difficulties with swallowing are frequent and are often underestimated by both patients and clinicians. Most patients present as adults, presumably because of ongoing diverticular growth. The diverticulum represents the remnant of the fourth primitive dorsal arch and is typically seen as a conical origin of the aberrant vessel. Even when its absolute size is only mildly increased, the vessel is rather thin and friable, possibly reflecting the failed tissue involution programming. Because of such intrinsic tissue abnormality, Backer and colleagues [1Backer C.L. Russell H.M. Wurlitzer K.C. et al.Primary resection of Kommerell diverticulum and left subclavian artery transfer.Ann Thorac Surg. 2012; 94: 1612-1618Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar] had proposed a ratio of 1.5 between the diameter at the mouth of the diverticulum and at the distal subclavian as the trigger to consider intervention. In this issue of The Annals of Thoracic Surgery, Ikeno and colleagues [2Ikeno Y. Koda Y. Yokawa K. et al.Graft replacement of Kommerell diverticulum and in situ aberrant subclavian artery reconstruction.Ann Thorac Surg. 2019; 107: 770-779Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar] report excellent results of surgical treatment of aberrant subclavian artery with Kommerell’s diverticulum in 17 patients over an 18-year period. Even within a group with an interest in arch anomalies such interventions were performed about once a year. It is remarkable that only 6 of 17 patients were symptomatic. Dysphagia progresses so slowly that many affected individuals are not even aware of their abnormal swallowing and are surprised by the strikingly different swallowing experience after the aberrant subclavian artery and diverticulum have been removed. However, in light of how well most patients are able to compensate for swallowing difficulties, it is imperative that our surgical treatment carry minimal mortality and morbidity. These authors have demonstrated outstanding results in the elective setting. Given the relatively focal aortic disease the option of endovascular treatment has been favorably considered by an increasing number of cardiovascular surgeons. In most instances the distance between the two subclavian arteries, which are typically 90 degrees off axis of each other, remains exceedingly short such that to achieve a seal at the proximal landing zone requires bilateral carotid-subclavian bypass/transposition. Even after adequate seal is achieved, the aberrant subclavian artery remains in situ and can continue to provide ongoing swallowing difficulty. Because most patients present early in their adult life an open intervention remains a low risk endeavor with predictably good long-term results. We have historically undertreated aberrant subclavian artery with Kommerell’s diverticulum for fear of causing more harm than good: Clearly only a high volume aortic center should tackle these rare anomalies to ensure negligible risk. The surgical treatment of aberrant subclavian artery should include removal of the aberrant vessel with suitable revascularization plus excision of Kommerell’s diverticulum with appropriate aortic reconstruction. Endovascular treatment should be considered in high-risk patients primarily to treat impending rupture. Graft Replacement of Kommerell Diverticulum and In Situ Aberrant Subclavian Artery ReconstructionThe Annals of Thoracic SurgeryVol. 107Issue 3PreviewThis study aimed to evaluate the early and long-term outcomes of graft replacement of Kommerell diverticulum and in situ reconstruction of aberrant subclavian arteries in adults. Full-Text PDF

Repair of Vascular Ring with Resection of Kommerell Diverticulum and Transposition of Aberrant Left Subclavian Artery

A 32-year-old female presented with dysphagia. Radiographic studies revealed external compression of esophagus by a vascular ring. The anatomy was a right-sided aortic arch with aberrant retroesophageal left subclavian artery, emanating from a large Kommerell diverticulum (KD). Traditional repair with ligamentum division and adhesiolysis leaves a large KD still adjacent to the esophagus with the potential for persistent or recurrent symptoms. The objective of this study was the modification of operative technique to minimize the potential for persistent or recurrent symptoms. The operative repair included resection of KD with transposition of the left subclavian artery into the left carotid artery, in addition to the division of the ligamentum arteriosum and mobilization of the esophagus. The patient's dysphagia resolved and postoperative barium studies showed no residual compression. There were no significant perioperative complications. Resection of KD is a potential adjunct to traditional repair of vascular rings and might offer better long-term palliation by minimizing residual vascular compression of the esophagus.

Resection of Kommerell's diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division.

A Kommerell's diverticulum in patients with a right aortic arch may become aneurysmal and be an independent cause of tracheoesophageal compression, even after ligation and division of a left ligamentum. We review the indications for and results of Kommerell's diverticulum resection and left subclavian artery transfer in children with a right aortic arch who previously underwent vascular ring (ligamentum) division. From 1998 through 2001, eight children have been referred with recurrent respiratory symptoms (n=8) and/or recurrent dysphagia (n=4) after vascular ring division. Each child had a right aortic arch with a left ligamentum and had undergone division of the ligamentum elsewhere. All had a Kommerell's diverticulum that was not addressed at the initial operation. All patients had a repeat left thoracotomy with resection of the diverticulum. Five patients had division and reimplantation of the left subclavian artery into the left carotid artery to relieve the sling-like effect of the retroesophageal left subclavian artery on the right aortic arch. One other patient had primary Kommerell's diverticulum resection and transfer of the left subclavian artery to the left carotid artery. The mean age at the initial operation was 1.7+/-0.9 years, and the mean age at reoperation was 8.0+/-3.7 years. In all patients postoperative bronchoscopy confirmed relief of the tracheal compression. There were no complications related to the subclavian artery transfer. Two patients developed postoperative chylothorax, one requiring thoracic duct ligation. The median hospital stay was 5 days. All patients had dramatic resolution of their preoperative symptoms. Kommerell's diverticulum is an important anatomic structure that can cause recurrent symptoms in patients with a right aortic arch after ligamentum division. In selected patients, reoperation with resection of the Kommerell's diverticulum and transfer of a retroesophageal left subclavian artery results in relief of symptoms. This technique has become our procedure of choice as a primary operation for children with a right aortic arch and a significant Kommerell's diverticulum.