Hybrid Management Of Acute Type B Aortic Dissection In A Patient With Right-sided Aortic Arch, Aberrant Left Subclavian Artery, And Kommerel Diverticulum
Regina Husman, MD, Madiha Hassan, Rana O. Afifi, MD, Anthony L. Estrera.
Division of Vascular Surgery, The University of Texas Health Science Center at Houston, Houston, TX, USA.
DEMOGRAPHICS: A 58-year-old Caucasian male smoker with a history of obesity, hypertension, and chronic obstructive pulmonary disease presented to our hospital with acute onset severe back pain. HISTORY: Computed tomographic angiography (CTA) demonstrated a right-sided aortic arch, an aberrant left subclavian artery with retroesophageal course, and a Kommerel diverticulum measuring 3.9 cm. In addition, there was dilatation of the aortic root measuring 4.2 cm, ascending aorta measuring 4.0 cm, and descending aorta measuring 6.0 cm. An acute Stanford Type B (2-10) aortic dissection was identified, with the true lumen providing perfusion to the celiac artery, superior mesenteric artery, and left renal artery and false lumen perfusing the right renal artery. PLAN: The patient was admitted to our intensive care unit and remained symptomatic despite medical management with anti-impulse therapy. Given aneurysmal degeneration from the aortic root to the descending thoracic aorta, we planned a two-stage hybrid approach. We first performed a valve-sparing aortic root replacement (David Procedure) and a transverse arch replacement with reattachment of the right innominate artery and bilateral common carotid arteries. A thoracic endovascular aneurysm (TEVAR) repair was then performed with coverage of the left subclavian artery. Using brachial artery access, a vascular occlusion plug was deployed in the left subclavian artery. Post-operatively, the patient developed left subclavian steal syndrome, and therefore a left carotid to subclavian bypass was subsequently performed. The patient tolerated the procedure well, with stable imaging findings during his three-year follow-up. DISCUSSION: A right-sided aortic arch with an aberrant left subclavian artery and Kommerrel diverticulum is a rare congenital anatomical variant that has been described in a few case reports. Given the rarity, surgical treatment of complications such as aneurysmal degeneration and dissection is limited. A successful outcome depends on meticulous preoperative imaging and careful consideration of the individual anatomy during surgical planning. Our report contributes to the limited body of literature on treating such complications, which was successfully treated with a hybrid approach. 
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