PDF(Pubmed)
Abstract：
BACKGROUND: Kommerell\'s diverticulum (KD) with a right aortic arch (RAA) and aberrant left subclavian artery (aLSCA) is a rare congenital anomaly of the aortic arch. Treatment is not well defined due to its uncommon presentation, with rupture and dissection risk rates of up to 53%.
METHODS: A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred.
CONCLUSIONS: We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.
METHODS: A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred.
CONCLUSIONS: We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.
摘要：
背景：带有右主动脉弓（RAA）和异常左锁骨下动脉（aLSCA）的Kommerel憩室（KD）是一种罕见的先天性主动脉弓异常。由于其罕见的表现，治疗并不明确，破裂和夹层风险高达53%。
方法：一名54岁男性，有慢性阻塞性肺疾病（COPD）和高血压病史，在运动过程中出现呼吸困难，无吞咽困难。后续计算机断层扫描血管造影（CTA）显示，下行胸主动脉出现RAA和aLSCA，相邻的58×41-mmKD以及气管和食管移位。由于KD的大小,破裂的风险，不适合全血管内主动脉修复术（EVAR）的解剖结构，和高COPD负担，该患者计划接受混合手术修复。左颈总动脉（LCCA）至LSCA旁路，全主动脉脱支,行LSCA栓塞和经皮胸主动脉腔内修复术（TEVAR）。完成胸主动脉造影后，观察到装置成功定位并排除憩室和动脉瘤主动脉。18个月随访CTA显示LSCA通畅至LCCA旁路移植物和弓血管分支，以及KD的稳定排除。已注意到起源于右第一肋间后动脉的II型内漏的持续存在，并且由于没有发生囊生长，因此正在保守地追踪。
结论：我们强调了有RAA和锁骨下动脉异常的KD的存在，罕见的先天性主动脉弓解剖变异，解剖复杂。手术计划必须根据成像和3D重建中发现的合并症和解剖变化进行个性化。
方法：一名54岁男性，有慢性阻塞性肺疾病（COPD）和高血压病史，在运动过程中出现呼吸困难，无吞咽困难。后续计算机断层扫描血管造影（CTA）显示，下行胸主动脉出现RAA和aLSCA，相邻的58×41-mmKD以及气管和食管移位。由于KD的大小,破裂的风险，不适合全血管内主动脉修复术（EVAR）的解剖结构，和高COPD负担，该患者计划接受混合手术修复。左颈总动脉（LCCA）至LSCA旁路，全主动脉脱支,行LSCA栓塞和经皮胸主动脉腔内修复术（TEVAR）。完成胸主动脉造影后，观察到装置成功定位并排除憩室和动脉瘤主动脉。18个月随访CTA显示LSCA通畅至LCCA旁路移植物和弓血管分支，以及KD的稳定排除。已注意到起源于右第一肋间后动脉的II型内漏的持续存在，并且由于没有发生囊生长，因此正在保守地追踪。
结论：我们强调了有RAA和锁骨下动脉异常的KD的存在，罕见的先天性主动脉弓解剖变异，解剖复杂。手术计划必须根据成像和3D重建中发现的合并症和解剖变化进行个性化。
