Emergent Hybrid Surgical Approaches for Non-Dissecting Ruptured Kommerell's Aneurysm: A Case Series

Abstract

Background Kommerell's diverticulum is a rare developmental abnormality of the aorta, associated in 20–60% of the cases with an aberrant subclavian artery. A Kommerell’s aneurysm is a saccular or fusiform dilatation that can be found in 3–8% of Kommerell’s diverticulum cases. A non-dissecting rupture rate of 6% has been reported. Because the patient's life is at risk, emergent surgical correction is usually granted. Different surgical interventions have been proposed, including open, endovascular, or hybrid approaches. However, evidence regarding the optimal surgical approach in the acute setting is scarce. In this case series, we aim to describe our surgical experience in the management of type-1 non-dissecting ruptured Kommerell's aneurysm. Cases presentation: From January 2005 to December 2020, three cases of type-1 non-dissecting ruptured Kommerell's aneurysm requiring emergent surgical repair were identified. The mean age was 66.67 ± 7.76 years, and 3/3 were male. The most common symptoms were atypical chest pain, dyspnea, and headache (2/3). The most frequent comorbidity was hypertension (2/3). The mean aneurysm’s diameter was 63.67 ± 5.69 mm. Frozen Elephant Trunk was the preferred surgical approach (2/3). The Non-Frozen Elephant Trunk patient underwent a hybrid procedure consisting of a carotid-subclavian bypass and a zone-2 stent graft deployment. We found a mean clamp time of 140 ± 60.75 min, cardiac arrest time of 51.33 ± 3.06 min, and a hospital stay of 13.67 ± 5.51 days. The most common complications were surgical-site infection and shock (2/3). Only one patient died (1/3). Conclusion Evidence involving the accurate diagnosis, prevention, and management of type-1 non-dissecting ruptured Kommerell's aneurysms is scarce. Additional, robust, and more extensive studies are required. The selection of the appropriate surgical approach is challenging. In our experience, Frozen Elephant Trunk was feasible for patients requiring emergent surgical repair. However, other hybrid procedures can be performed.

Challenges in prompt identification and surgical correction of Marfan Syndrome aortic disease in a middle-income country: a case series study

“…This approach aims to reduce the occurrence of Type I and Type III endoleaks or the displacement of the stent-graft and provide an instrument for incoming surgeries if needed [20,21]. The method involves accessing the aortic arch through a sternotomy and directly suturing the stent graft to facilitate a more secure fixation within the aortic arch repair [23]. The study published by Widenka et al supported this argument, as 37 patients with MFS who underwent a FET were analyzed and at 5 years of follow-up, no aortic arch reinterventions were required [21].…”

Challenges in Prompt Identification and Surgical Correction of Marfan Syndrome Aortic Disease in a middle-income Country: A Case Series Study.

“…This approach aims to reduce the occurrence of Type I and Type III endoleaks or the displacement of the stent-graft and provide an instrument for incoming surgeries if needed (20,21). The method involves accessing the aortic arch through a sternotomy and directly suturing the stent-graft to facilitate a more secure xation within the aortic arch repair (23). The study published by Widenka et al supported this argument, as 37 patients with MFS who underwent a FET were analyzed and at 5 years-follow up no aortic arch reinterventions were required (21).…”