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)