Supervisors info:
Καθηγητής Γεώργιος Γερουλάκος Επιβλέπων , Αν. Καθηγητής Ιωάννης Κακίσης,Αν. Καθηγητής Χρήστος Κλωνάρης
Summary:
The aberrant right subclavian artery origin from the aortic arch is a known
anatomic variant, which can be found in 0.4 – 2.0 % of the population and
although it is usually asymptomatic, it can be accompanied by dysphagia. In 60%
of the cases, there is a dilated segment of the proximal descending aorta, the
so-called “Diverticulum of Kommerell”. The aberrant left subclavian artery is
extremely rare and it is usually found along with right aortic arch and
diverticulum. The aim of the study is the systematic review of the literature,
concerning the diverticulum of Kommerell, with a special focus on methods of
open and endovascular treatment. The risk for rupture or dissection of the
diverticulum is between 19-55%. The diagnostic evaluation consists of chest
x-ray, barium swallow, gastroscopy, esophageal manometry, Computed Tomography
scan with IV contrast and Magnetic Resonance Angiography. However, Digital
Subtraction Angiography remains the gold standard. The conservative treatment
is usually followed by a 19% risk for rupture of the aneurysm and in that case,
mortality approaches 100%. The open surgical treatment of the Kommerell’
diverticulum includes: 1) replacement of the descending aorta with
reimplantation of the subclavian artery with circulatory arrest and deep
hypothermia, 2) replacement of the descending aorta with left heart bypass, 3)
endoaneurysmorrhaphy and carotid – subclavian bypass in two stages without the
use of extracorporeal circulation, iv) endoaneurysmorrhaphy and
aorto-subclavian bypass under extracorporeal circulation and v) arch and part
of the descending aorta replacement. More sophisticated open procedures include
the “elephant trunk” and the “frozen elephant trunk”. The endovascular repair
includes i) the thoracic endovascular aortic repair; TEVAR and aorto-subclavian
bypass, ii) TEVAR and aorto-carotid bypass and bilateral carotid – subclavian
pass and iii) the exclusively endovascular repair with proximal landing in zone
2. According to the literature review, it has been proposed that Kommerell’
diverticulum should be repaired soon after the diagnosis, irrespectively of the
size, due to the increased risk of rupture or dissection. The endovascular
repair seems to be less traumatic for the patient, due to the non-use of
extracorporeal circulatory arrest. However, the absence of long-term results
and the variants in aortic arch anatomy do not allow for sound conclusions,
concerning the use of endovascular methods in low-risk patients, which should
be ideally treated with open repair.
