Single-stage repair of complex aortic arch anomaly with aortic regurgitation

Abstract

Aneurysm of the aberrant left subclavian artery arising from Kommerell's diverticulum is very rare. Early intervention is recommended in such a case to avoid complications. Rarely, such an aneurysm may present with a concomitant cardiac pathology. Surgical approach in this complex scenario is difficult as anatomically distant areas have to be exposed and usually a staged approach is preferred. There are only a few published reports about the same. We report, for the first time, successful single-stage intervention in a patient with aortic regurgitation, right aortic arch, and aneurysmal aberrant left subclavian artery from Kommerell's diverticulum, exclusively through median sternotomy. A 37-year-old gentleman presented with the complaints of palpitations (New York Heart Association grade II) and left-sided neck swelling of 4 months' duration. He also had history of hoarseness of voice for 2 weeks. He was diagnosed to have aortic regurgitation, right aortic arch, and aneurysmal aberrant left subclavian artery from Kommerell's diverticulum and was treated by single-stage repair of the aneurysm and aortic valve replacement with mechanical prosthesis via median sternotomy. Single-stage intervention through midline sternotomy provides excellent outcomes and can be a feasible option for such a complex aortic anomaly.

Keywords: Complex aortic arch anomaly; Kommerell’s diverticulum; Single-stage aneurysm repair.

Fig. 1

Pre-operative computed tomography aortogram, ALSCA with Kommerell’s diverticulum (arrow)

Fig. 2

Intra-operative picture; (a) Kommerell’s diverticulum; (b) cannulated right aortic arch giving rise to left carotid, right carotid, and right subclavian (not seen) in that order; (c) ALSCA; (d) completed aortic valve replacement

Fig. 3

Post-operative computed tomography aortogram, PTFE graft placed between the distal normal walled ALSCA and ascending aorta (arrow)