Efficacy of stented elephant trunk procedure for right-sided aortic arch with Kommerell's diverticulum_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHONG Yongliang , TANG Bing , CHEN Suwei , GE Yipeng , HU Hai'ou , QIAO Zhiyu , LI Chengnan , LIU Yongmin ,  ZHU Junming

Department of Cardiovascular Surgery and Aortic Surgery Center, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Aortic Disease Center, Beijing, 100029, P. R. China;

Corresponding author：

ZHU Junming, Email: anzhenzjm@163.com

Keywords：

Stented elephant trunk procedure; right-sided aortic arch; Kommerell’s diverticulum; aberrant left subclavian artery; aortic aneurysm

DOI：

10.7507/1007-4848.202211031

Video：

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Objective To summarize our experience and the early and midterm outcomes of stented elephant trunk procedure for right-sided aortic arch (RAA) with Kommerell's diverticulum (KD). Methods From April 2013 to July 2020, patients with RAA and KD who underwent stented elephant trunk procedure at our center were collected. Surgery was performed under moderate hypothermic circulatory arrest combined with selective antegrade cerebral perfusion via median sternotomy. Results A total of 8 patients were included, including 7 males and 1 female with a mean age of 51.88±9.61 years. All patients had an aneurysmal KD and aberrant left subclavian artery. Preoperative comorbidities included acute Stanford type B aortic dissection in 1 patient, aortic arch pseudoaneurysm in 1 patient, acute type B intramural hematoma in 2 patients, and coronary artery disease in 1 patient. Concomitant procedures included reconstruction of the left subclavian artery in all patients and coronary artery bypass grafting in 1 patient. The mean time of operation, cardiopulmonary bypass, aortic cross-clamping, and selective cerebral perfusion was 6.25±1.16 h, 157.75±40.07 min, 77.75±33.10 min, and 28.50±5.55 min, respectively. No intraoperative death occurred. There was 1 in-hospital death. Follow-up was completed in all patients with a mean period of 3.58±2.08 years. No late death occurred. A persistent anastomotic leak of the proximal arch was detected in 1 patient, but reintervention was not performed because neither aortic dilatation nor symptoms of tracheal and esophageal compression were observed during the follow-up. The remaining 6 patients showed positive aortic remodeling with complete thrombosis of the aneurysmal KD, and neither aortic event nor tracheal and esophageal compression occurred. Conclusion Stented elephant trunk procedure is a safe and feasible technique for selected patients with RAA and KD, which can achieve favorable early and midterm outcomes.

Citation： ZHONG Yongliang, TANG Bing, CHEN Suwei, GE Yipeng, HU Hai'ou, QIAO Zhiyu, LI Chengnan, LIU Yongmin, ZHU Junming. Efficacy of stented elephant trunk procedure for right-sided aortic arch with Kommerell's diverticulum. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(7): 1020-1026. doi: 10.7507/1007-4848.202211031 Copy

1.	Knight L, Edwards JE. Right aortic arch. Types and associated cardiac anomalies. Circulation, 1974, 50(5): 1047-1051.
2.	Biermann D, Holst T, Huners I, et al. Right aortic arch forming a true vascular ring: A clinical review. Eur J Cardiothorac Surg, 2021, 60(5): 1014-1021.
3.	Erben Y, Brownstein AJ, Velasquez CA, et al. Natural history and management of Kommerell's diverticulum in a single tertiary referral center. J Vasc Surg, 2020, 71(6): 2004-2011.
4.	Barr JG, Sepehripour AH, Jarral OA, et al. A review of the surgical management of right-sided aortic arch aneurysms. Interact Cardiovasc Thorac Surg, 2016, 23(1): 156-162.
5.	Ota T, Okada K, Takanashi S, et al. Surgical treatment for Kommerell's diverticulum. J Thorac Cardiovasc Surg, 2006, 131(3): 574-578.
6.	Kim KM, Cambria RP, Isselbacher EM, et al. Contemporary surgical approaches and outcomes in adults with Kommerell diverticulum. Ann Thorac Surg, 2014, 98(4): 1347-1354.
7.	Tsukui H, Aomi S, Yamazaki K. Surgical strategy for Kommerell's diverticulum: Total arch replacement. J Thorac Cardiovasc Surg, 2014, 148(4): 1423-1427.
8.	Vinnakota A, Idrees JJ, Rosinski BF, et al. Outcomes of repair of Kommerell diverticulum. Ann Thorac Surg, 2019, 108(6): 1745-1750.
9.	Idrees J, Keshavamurthy S, Subramanian S, et al. Hybrid repair of Kommerell diverticulum. J Thorac Cardiovasc Surg, 2014, 147(3): 973-976.
10.	Rizza A, De Caterina AR, Murzi M, et al. Double carotid-subclavian bypass followed by endovascular exclusion of a Kommerell diverticulum and bilateral subclavian artery occlusion in a right-sided aortic arch. JACC Cardiovasc Interv, 2019, 12(9): e81-e82.
11.	Marzouki S, Peeters B, Gevaert S, et al. Right-sided aortic arch with Kommerell's diverticulum: A case report of a rare cause of type B dissection. Eur Heart J Case Rep, 2022, 6(6): ytac238.
12.	Loschi D, Santoro A, Rinaldi E, et al. A systematic review of open, hybrid, and endovascular repair of aberrant subclavian artery and Kommerell's diverticulum treatment. J Vasc Surg, 2023, 77(2): 642-649.e4.
13.	Gao P, Wang M, Dong D, et al. Endovascular repair of a Kommerell diverticulum anomaly. Ann Thorac Surg, 2015, 99(5): 1801-1803.
14.	Li Z, Wu R, Liu C, et al. Endovascular repair for Kommerell diverticulum with type A aortic dissection. Ann Thorac Surg, 2020, 110(3): e217-e219.
15.	齐瑞东, 朱俊明, 陈雷, 等. 左锁骨下动脉-左颈总动脉转流术联合支架象鼻术治疗主动脉弓远端病变. 中国胸心血管外科临床杂志, 2018, 25(1): 49-53.
16.	Chourda E, Putotto C, Versacci P, et al. Hybrid single-stage repair of Kommerell's diverticulum in a right aortic arch in a patient with 22q11. 2 deletion syndrome. Vasc Endovascular Surg, 2022, 56(6): 595-601.
17.	Perolo A, De Robertis V, Cataneo I, et al. Risk of 22q11. 2 deletion in fetuses with right aortic arch and without intracardiac anomalies. Ultrasound Obstet Gynecol, 2016, 48(2): 200-203.
18.	Yu D, Guo Z, You X, et al. Long-term outcomes in children undergoing vascular ring division: A multi-institution experience. Eur J Cardiothorac Surg, 2022, 61(3): 605-613.
19.	Bloom JP, Attia RQ, Sundt TM, et al. Outcomes of open and endovascular repair of Kommerell diverticulum. Eur J Cardiothorac Surg, 2021, 60(2): 305-311.
20.	Czerny M, Schmidli J, Adler S, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: An expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg, 2019, 55(1): 133-162.
21.	Hale BW, Lu JC, Romano JC, et al. Kommerell diverticulum: Distinctions between arch side and evaluation of morphology, size, and risk. Ann Thorac Surg, 2022, 114(3): 848-856.
22.	Backer CL, Russell HM, Wurlitzer KC, et al. Primary resection of Kommerell diverticulum and left subclavian artery transfer. Ann Thorac Surg, 2012, 94(5): 1612-1617.
23.	Tanaka Y, Kitamura T, Irisawa Y, et al. Total arch replacement using the Gelweave Lupiae graft for an aneurysm arising from Kommerell's diverticulum with an aberrant left subclavian artery and right-sided aortic arch. Interact Cardiovasc Thorac Surg, 2018, 27(2): 307-309.
24.	Nagata T, Iwakoshi S, Yamada T, et al. Total arch replacement with the frozen elephant trunk technique for a right-sided aortic arch with a Kommerell diverticulum and aberrant right vertebral artery. Interact Cardiovasc Thorac Surg, 2022, 35(2): ivac075.
25.	Hashimoto M, Fukui T, Takanashi S. Surgical treatment for chronic type B aortic dissection originating from a Kommerell diverticulum with right-sided aortic arch. Eur J Cardiothorac Surg, 2014, 46(4): 753.
26.	Morishita A, Tomioka H, Katahira S, et al. Surgical treatment for Kommerell's diverticulum associated with a right-sided aortic arch and an aberrant left subclavian artery: Endovascular or hybrid. Ann Vasc Dis, 2019, 12(2): 228-232.
27.	Zhong YL, Qi RD, Ma WG, et al. Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection. J Thorac Dis, 2018, 10(9): 5376-5383.
28.	Qiao Z, Chen S, Guo R, et al. Comparison of open repair vs. the one-stage hybrid extra-anatomic technique for distal aortic arch disease treatment: Midterm outcomes with a risk-adjusted analysis. Front Cardiovasc Med, 2021, 8: 725902.

1. Knight L, Edwards JE. Right aortic arch. Types and associated cardiac anomalies. Circulation, 1974, 50(5): 1047-1051.
2. Biermann D, Holst T, Huners I, et al. Right aortic arch forming a true vascular ring: A clinical review. Eur J Cardiothorac Surg, 2021, 60(5): 1014-1021.
3. Erben Y, Brownstein AJ, Velasquez CA, et al. Natural history and management of Kommerell's diverticulum in a single tertiary referral center. J Vasc Surg, 2020, 71(6): 2004-2011.
4. Barr JG, Sepehripour AH, Jarral OA, et al. A review of the surgical management of right-sided aortic arch aneurysms. Interact Cardiovasc Thorac Surg, 2016, 23(1): 156-162.
5. Ota T, Okada K, Takanashi S, et al. Surgical treatment for Kommerell's diverticulum. J Thorac Cardiovasc Surg, 2006, 131(3): 574-578.
6. Kim KM, Cambria RP, Isselbacher EM, et al. Contemporary surgical approaches and outcomes in adults with Kommerell diverticulum. Ann Thorac Surg, 2014, 98(4): 1347-1354.
7. Tsukui H, Aomi S, Yamazaki K. Surgical strategy for Kommerell's diverticulum: Total arch replacement. J Thorac Cardiovasc Surg, 2014, 148(4): 1423-1427.
8. Vinnakota A, Idrees JJ, Rosinski BF, et al. Outcomes of repair of Kommerell diverticulum. Ann Thorac Surg, 2019, 108(6): 1745-1750.
9. Idrees J, Keshavamurthy S, Subramanian S, et al. Hybrid repair of Kommerell diverticulum. J Thorac Cardiovasc Surg, 2014, 147(3): 973-976.
10. Rizza A, De Caterina AR, Murzi M, et al. Double carotid-subclavian bypass followed by endovascular exclusion of a Kommerell diverticulum and bilateral subclavian artery occlusion in a right-sided aortic arch. JACC Cardiovasc Interv, 2019, 12(9): e81-e82.
11. Marzouki S, Peeters B, Gevaert S, et al. Right-sided aortic arch with Kommerell's diverticulum: A case report of a rare cause of type B dissection. Eur Heart J Case Rep, 2022, 6(6): ytac238.
12. Loschi D, Santoro A, Rinaldi E, et al. A systematic review of open, hybrid, and endovascular repair of aberrant subclavian artery and Kommerell's diverticulum treatment. J Vasc Surg, 2023, 77(2): 642-649.e4.
13. Gao P, Wang M, Dong D, et al. Endovascular repair of a Kommerell diverticulum anomaly. Ann Thorac Surg, 2015, 99(5): 1801-1803.
14. Li Z, Wu R, Liu C, et al. Endovascular repair for Kommerell diverticulum with type A aortic dissection. Ann Thorac Surg, 2020, 110(3): e217-e219.
15. 齐瑞东, 朱俊明, 陈雷, 等. 左锁骨下动脉-左颈总动脉转流术联合支架象鼻术治疗主动脉弓远端病变. 中国胸心血管外科临床杂志, 2018, 25(1): 49-53.
16. Chourda E, Putotto C, Versacci P, et al. Hybrid single-stage repair of Kommerell's diverticulum in a right aortic arch in a patient with 22q11. 2 deletion syndrome. Vasc Endovascular Surg, 2022, 56(6): 595-601.
17. Perolo A, De Robertis V, Cataneo I, et al. Risk of 22q11. 2 deletion in fetuses with right aortic arch and without intracardiac anomalies. Ultrasound Obstet Gynecol, 2016, 48(2): 200-203.
18. Yu D, Guo Z, You X, et al. Long-term outcomes in children undergoing vascular ring division: A multi-institution experience. Eur J Cardiothorac Surg, 2022, 61(3): 605-613.
19. Bloom JP, Attia RQ, Sundt TM, et al. Outcomes of open and endovascular repair of Kommerell diverticulum. Eur J Cardiothorac Surg, 2021, 60(2): 305-311.
20. Czerny M, Schmidli J, Adler S, et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: An expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg, 2019, 55(1): 133-162.
21. Hale BW, Lu JC, Romano JC, et al. Kommerell diverticulum: Distinctions between arch side and evaluation of morphology, size, and risk. Ann Thorac Surg, 2022, 114(3): 848-856.
22. Backer CL, Russell HM, Wurlitzer KC, et al. Primary resection of Kommerell diverticulum and left subclavian artery transfer. Ann Thorac Surg, 2012, 94(5): 1612-1617.
23. Tanaka Y, Kitamura T, Irisawa Y, et al. Total arch replacement using the Gelweave Lupiae graft for an aneurysm arising from Kommerell's diverticulum with an aberrant left subclavian artery and right-sided aortic arch. Interact Cardiovasc Thorac Surg, 2018, 27(2): 307-309.
24. Nagata T, Iwakoshi S, Yamada T, et al. Total arch replacement with the frozen elephant trunk technique for a right-sided aortic arch with a Kommerell diverticulum and aberrant right vertebral artery. Interact Cardiovasc Thorac Surg, 2022, 35(2): ivac075.
25. Hashimoto M, Fukui T, Takanashi S. Surgical treatment for chronic type B aortic dissection originating from a Kommerell diverticulum with right-sided aortic arch. Eur J Cardiothorac Surg, 2014, 46(4): 753.
26. Morishita A, Tomioka H, Katahira S, et al. Surgical treatment for Kommerell's diverticulum associated with a right-sided aortic arch and an aberrant left subclavian artery: Endovascular or hybrid. Ann Vasc Dis, 2019, 12(2): 228-232.
27. Zhong YL, Qi RD, Ma WG, et al. Frozen elephant trunk with modified en bloc arch reconstruction and left subclavian transposition for chronic type A dissection. J Thorac Dis, 2018, 10(9): 5376-5383.
28. Qiao Z, Chen S, Guo R, et al. Comparison of open repair vs. the one-stage hybrid extra-anatomic technique for distal aortic arch disease treatment: Midterm outcomes with a risk-adjusted analysis. Front Cardiovasc Med, 2021, 8: 725902.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Efficacy of stented elephant trunk procedure for right-sided aortic arch with Kommerell's diverticulum

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