Case Report
This is a 62-year-old African American male with hypertension who presented to the emergency department with acute onset tearing chest pain. Computed Tomography Angiography (CTA) demonstrated aneurysmal AAo, AoA, and DTA IMH with contained rupture of diverticulum of Kommerell with associated aberrant right subclavian artery.
The ARSA originated on the lesser curvature of the distal aortic arch, directly across from the left subclavian artery, and coursed posterior to the trachea and esophagus to supply the right arm (Figure 1). Because of the proximity of the diverticulum to the left subclavian (LSCA), its proximity to the left carotid takeoff, and the IMH extending across the AAo, AoA, and DTA, there was no adequate proximal landing zone for placement of an endograft. Thus, the operative plan was to perform right carotid subclavian bypass (dominant right vertebral artery), followed by open AAo zone II arch replacement with proximal intrathoracic ligation of ARSA and LSCA, open debranching of the bilateral carotid arteries, followed by a retrograde TEVAR.
Right carotid-subclavian artery bypass was done with 8 mm graft. A median sternotomy was performed. Cardiopulmonary bypass was initiated through central cannulation and cooling was initiated. Of note, the aortic root was not aneurysmal. A 32mm straight graft was sewn just above the sinotubular junction. Once the patient was adequately cooled, deep hypothermic circulatory arrest with ostial antegrade cerebral perfusion into both carotid arteries was initiated. The remainder of the ascending aorta and the entire arch was resected proximal to LSCA for zone II arch replacement. The ruptured Kommerell’s diverticulum was noted coming off the lesser curvature opposite the left subclavian artery. (Figure 2) The diverticulum was large, spanning 4 cm along the distal arch and proximal descending thoracic aorta. (Figure 2) The carotid arteries were first de-branched using a 14 mm bifurcated side branch. Attention was then turned back to the diverticulum and ARSA. Dissection was carried into the posterior mediastinum, deep to the trachea and esophagus, and its transition to the right subclavian artery was identified. We ligated the vessel at this point, and also proximally at the aortic takeoff using multiple 4-0 prolene pledgeted sutures. Arch replacement was then performed using a 32mm straight graft, along with ligation of the left subclavian artery. Then an antegrade TEVAR, using a 38x200mm Bolton Relay thoracic endograft, was performed to cover the tear site. A guidewire was passed into the descending thoracic aorta true lumen under both ultrasound and fluoroscopy guidance. The stent graft was then deployed, with the proximal landing zone within the 32mm straight graft. A graft-to-graft connection was performed to complete the operation.
Angiography demonstrated a type Ia endoleak, even though the endograft was landed into the aortic arch graft. Thus, we proceeded to perform retrograde TEVAR via a right femoral artery cutdown. A 42x115mm Bolon Relay thoracic stent graft was advanced into the AAo graft just distal to the carotid side branch and deployed. Completion angiography demonstrated no further filling of the aneurysm sac. A bronchoscopy was performed to confirm no injury to the trachea and intact vocal cord function. Completion angiography and imaging at 3 months showed intact repair without endoleak. (Figure 3)