Two Cases of Descending Aortic Diverticulum Associated with the Right-Sided Aortic Arch / 日本心臓血管外科学会雑誌

Case 1 is a 70-year-old male. He has a history of cholelithiasis and left inguinal hernia. A preoperative examination of the inguinal hernia showed the enlargement of the mediastinal shadow, and he was referred to our department. A close examination revealed a right-sided aortic arch, a right descending aorta, and a descending aortic diverticulum. No subjective symptoms, intracardiac malformations, or other cardiovascular diseases were observed. The surgery was scheduled for descending aorta replacement including a diverticulum with right posterior lateral 4th intercostal thoracotomy and lower body partial extracorporeal circulation. However, due to aortic intima injury at the proximal end, hypothermic cerebral circulatory arrest and proximal anastomosis were performed by the open proximal method. There was no problem with the postoperative course, and he was discharged 19 days after surgery. Case 2 is a 51-year-old female. Born in China, she has lived in Japan for 15 years. No notable history. An abnormal shadow was shown on chest Xp performed in a medical examination, and aortic malformation was suspected on chest CT. She was referred to our department. The diagnosis was right-sided aortic arch, right descending aorta, aberrant left subclavian artery, and Kommerell diverticulum. There were no subjective symptoms and no intracardiac malformations. The operation was a two-stage operation. As the initial surgery, median sternotomy was performed, total arch replacement with intrathoracic reconstruction of the left subclavian artery, and open stent graft insertion, and the Kommerell diverticulum was covered with an open stent graft. We did not treat the diverticulum because it was located on the dorsal side. At 15 days after surgery, we performed embolization of the origin of the left subclavian artery from the Kommerell diverticulum. There was no problem with the postoperative course, and she was discharged 19 days after the initial surgery.

Progress in surgical treatment of Kommerell's diverticulum / 中国胸心血管外科临床杂志

@#Kommerell's diverticulum is a rare congenital abnormal aortic development. The diverticulum can occur in both left and right aortic arches, from which an aberrant subclavian artery rises to the contralateral side. Only a small number of patients with Kommerell's diverticulum present symptoms. Dysphagia, dyspnea, chest discomfort and upper extremity blood pressure difference are common in adult patients. The risk of aortic dissection or aortic aneurysm rupture is higher in such patients than that in patients with normal aorta. Early surgical intervention is recommended to improve the prognosis. Treatment options include open surgical repair, hybrid operation and total endovascular repair. The choice of surgical method depends on the specific anatomy of patients, the patients' state and the preference of surgeons. This paper reviewed and summarized the surgical methods and early results of the treatment of Kommerell's diverticulum reported in the literature from 2015 to 2020.

Clinical analysis of surgical correction for congenital vascular ring in children in a single center / 中国胸心血管外科临床杂志

@#Objective    To investigate the best anatomical classification, surgical timing, procedure and clinical outcomes of congenital vascular ring. Methods    The clinical data of 58 patients who underwent congenital vascular ring surgery in Pediatric Surgery Center, Fuwai Hospital between 2014 and 2019 were retrospectively analyzed. There were 32 (55.2%) males and 26 (44.8%) females with a median age of 16.5 (2-73) months. Preoperative symptoms, imaging examinations, anatomical classifications, surgical procedures and postoperative recovery were assessed. Results    There were 20 (34.5%) patients of double aortic arch, 22 (37.9%) patients of right aortic arch with left arterial duct or ligament, 15 (25.9%) patients of left aortic arch with aberrant right subclavian artery, and 1 (1.7%) patient of circumflex aorta with cervical aorta arch. The median ventilator supporting time was 6.0 (0-648) h, and the median hospital stay time was 14.5 (7-104) d. One patient with coarctation of aorta died of severe pulmonary infection during perioperative period, and the others survived without symptoms and reoperation after discharge. The median follow-up time was 7.0 (1-62) months. Conclusion    For children with unexplained dyspnea and dysphagia, or with right aortic arch, preoperative imaging examinations such as computed tomography or magnetic resonance imaging are required to confirm the diagnosis of vascular ring. Surgical correction of congenital vascular ring is safe and reliable, and can effectively relieve symptoms. The mortality rate and reoperation rate are low, and the follow-up results are satisfactory.

Arteria subclavia derecha retroesofágica: reporte de caso / Right retroesophageal subclavian artery: case report

RESUMEN: Durante el desarrollo embrionario suelen ocurrir anomalías a nivel del arco aórtico primordial. Una de estas es la arteria subclavia retroesofágica derecha (ASDR) la cual es un defecto frecuente de los arcos aórticos embriológicos y se debe a la interrupción del cuarto arco aórtico (AO) derecho entre las depresiones para la arteria carótida común y la arteria subclavia. Las variaciones anatómicas y morfológicas del AO y sus ramas son significativas para los procedimientos diagnósticos y quirúrgicos en el tórax y el cuello. Reportar una ASDR encontrada durante disección, correlacionando esta con sus implicancias clínicas. De un cadáver de sexo femenino, de edad y causa de muerte desconocida, fijado con formaldehído al 10 % y aguada destilada. Se realizó disección del corazón y los grandes vasos, en especial el AO, desarrollado según la técnica convencional, para remover el órgano luego de disecar el pericardio y disecar la arteria aorta ascendente y el AO, preservando plenamente su configuración externa y sus ramas colaterales, donde se encontró la ASDR. La ASDR presentó un diámetro en su origen de 12,13 mm. La longitud existente entre la ASDR y la Arteria carótida común Derecha (ACCD) fue de 43,84 mm. El diámetro del esófago a nivel cefálico y caudal de la ASDR alcanzó valores de 17,59 mm y 13,82 mm respectivamente. Por su parte los diámetros de la tráquea a nivel cefálico y caudal a la ASDR, fueron respectivamente 22,12 mm y 13,30 mm. El conocimiento de esta variante anatómica resulta de gran interés a la hora de interpretar y orientar el diagnóstico de las posibles causas de una disfagia asociada a una arteria subclavia retroesofágica y fundamenta aún más la importancia del estudio mediante disección.

SUMMARY: During embryonic development, anomalies usually occur at the primordial aortic arch (AA) level. One of these is the right retroesophageal subclavian artery (RSA). The anatomical and morphological variations of AA and its branches are significant for diagnostic and surgical procedures in the thorax and neck. The objective of the study was to report an RSA found during the dissection, correlating this with the corresponding clinical implications. A human female cadaver of unknown age and cause of death was used and conserved in 10 % formaldehyde and distilled wash. The dissection of the heart and large vessels was performed. There was particular emphasis one the AA, and development according to conventional techniques, removing the organ after dissecting the pericardium and dissecting the ascending aorta and the AA. External function and its collateral branches were fully preserved, where the RSA was located. The RSA presented a diameter at its origin of 12.13 mm. The length between the RSA and the common right carotid artery (CRCA) was 43.84 mm. The diameter of the esophagus at the cephalic and caudal level of the RSA has values of 17.59 mm and 13.82 mm respectively. Furthermore, the diameters of the trachea at cephalic and caudal level to the RSA, respectively, were 22.12 mm and 13.30 mm. Knowledge of this anatomical variant is of great interest when interpreting and guiding the diagnosis of potential causes of a dysphagia associated with a retroesophageal subclavian artery, and is even more important during dissection studies.

Anillos vasculares: Serie de 28 pacientes atendidos en un Servicio de Endoscopía Respiratoria Pediátrica / Vascular rings: Series of 28 patients of a Pediatrie Respiratory Endoscopy Department

Los anillos vasculares tienen una incidencia del 1 % entre las enfermedades cardiovasculares congénitas. Constituyen una malformación embriológica en la que el arco aórtico, sus ramas o las arterias pulmonares provocan presión sobre la tráquea y/o el esófago. Anatómicamente, se dividen en dos grupos, dependiendo de cómo rodean la tráquea y el esófago: completo o incompleto. La sintomatología suele iniciarse en los primeros meses de vida con estridor bifásico o espiratorio que aumenta con el llanto y la alimentación, tos traqueal de tonalidad metálica, infecciones respiratorias recurrentes, episodios de apnea refleja y cianosis, sibilancias, hiperextensión cervical, retracción esternal e intercostal, y dificultad en la alimentación. Se realizó un análisis retrospectivo de 28 pacientes con diagnóstico de anillo vascular que concurrieron a la consulta en el Servicio de Endoscopía Respiratoria del Hospital Garrahan entre enero de 2015 y septiembre de 2017.

Vascular rings account for 1 % of the congenital cardiovascular diseases. They constitute an embryological malformation in which the aortic arch, its branches, or the pulmonary arteries cause pressure on the trachea and/or oesophagus. Anatomically, they are divided into two groups -complete or incomplete- depending on how they surround the trachea and/or the oesophagus. Symptom onset is usually in the first months of life with biphasic or expiratory stridor that increases with crying and feeding, a metallic tracheal cough, recurrent respiratory infections, episodes of apnea and cyanosis, wheezing, cervical hyperextension, sternal and intercostal retraction, and feeding difficulties. A retrospective analysis of 28 patients with vascular rings seen at the Department of Respiratory Endoscopy at Garrahan Paediatric Hospital between January 2015 and September 2017 is presented.

Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea

OBJECTIVE: Aberrant right subclavian artery (ARSA) is a rare anatomical variant of the origin of the right subclavian artery. ARSA is defined as the right subclavian artery originating as the final branch of the aortic arch. The purpose of this study is to determine the prevalence and the anatomy of ARSA evaluated with computed tomography (CT) angiography. METHODS: CT angiography was performed in 3460 patients between March 1, 2014 and November 30, 2015 and the results were analyzed. The origin of the ARSA, course of the vessel, possible inadvertent ARSA puncture site during subclavian vein catheterization, Kommerell diverticula, and associated vascular anomalies were evaluated. We used the literature to review the clinical importance of ARSA. RESULTS: Seventeen in 3460 patients had ARSA. All ARSAs in 17 patients originated from the posterior aspect of the aortic arch and traveled along a retroesophageal course to the right thoracic outlet. All 17 ARSAs were located in the anterior portion from first to fourth thoracic vertebral bodies and were located near the right subclavian vein at the medial third of the clavicle. Only one of 17 patients presented with dysphagia. CONCLUSION: It is important to be aware ARSA before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral approach.

Hybrid Repair in a Patient with Kommerell Diverticulum and Right Aortic Arch / 日本心臓血管外科学会雑誌

We experienced a hybrid repair for Kommerell diverticulum and right aortic arch. A 62-year-old man with dyspnea and dysphagia was referred to our hospital. He underwent atrium septum defect closure when he was 15 years old and was found to have ventricular septal defect and severe aortic regurgitation at the referring hospital. Preoperative computed tomography incidentally showed right aortic arch and Kommerell diverticulum with aberrant left subclavian artery. First, we performed ventricular septal defect closure and aortic valve replacement. Three months later, we performed one-stage hybrid repair of Kommerell diverticulum that included left common carotid-subclavian artery bypass, left subclavian artery plug occlusion and descending aortic replacement via a right thoracotomy. This hybrid strategy did not require in-situ reconstruction of the aberrant subclavian artery and minimized the risk of bleeding, injuries of esophagus and recurrent laryngeal nerve. The postoperative course was uneventful. This hybrid repair is a safe and effective procedure for Kommerell diverticulum with aberrant subclavian artery.

Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea

OBJECTIVE: Aberrant right subclavian artery (ARSA) is a rare anatomical variant of the origin of the right subclavian artery. ARSA is defined as the right subclavian artery originating as the final branch of the aortic arch. The purpose of this study is to determine the prevalence and the anatomy of ARSA evaluated with computed tomography (CT) angiography.METHODS: CT angiography was performed in 3460 patients between March 1, 2014 and November 30, 2015 and the results were analyzed. The origin of the ARSA, course of the vessel, possible inadvertent ARSA puncture site during subclavian vein catheterization, Kommerell diverticula, and associated vascular anomalies were evaluated. We used the literature to review the clinical importance of ARSA.RESULTS: Seventeen in 3460 patients had ARSA. All ARSAs in 17 patients originated from the posterior aspect of the aortic arch and traveled along a retroesophageal course to the right thoracic outlet. All 17 ARSAs were located in the anterior portion from first to fourth thoracic vertebral bodies and were located near the right subclavian vein at the medial third of the clavicle. Only one of 17 patients presented with dysphagia.CONCLUSION: It is important to be aware ARSA before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral approach.

Surgical Treatment of Kommerell Diverticulum and the Aberrant Subclavian Artery : Four Case Reports / 日本心臓血管外科学会雑誌

<p>We report 4 cases of aortic graft replacement for Kommerell diverticulum (KD) and the aberrant subclavian artery (ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and <i>in-situ </i>reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.</p>

A Case of Kommerell's Diverticulum with Aortic Dissection

In 1936, a German radiologist, Burckhard Kommerell, reported a rare variant of thoracic aortic aneurysm named Kommerell's diverticulum which may be accompanied by an aberrant origin of the right subclavian artery. The most common type of Kommerell's diverticulum is the right-sided aortic arch, with the aberrant left subclavian artery. Kommerell's diverticulum is associated with a high risk of early rupture, and 20% is accompanied with aortic dissection. However, because Kommerell's diverticulum is rare, it is highly probably for emergency physicians to overlook the abnormal findings from a chest X-ray or dismiss the potential risk of early rupture and aortic dissection. Symptoms of Kommerell's diverticulum are not specific, like chest pain, dyspnea, swallowing difficulty, and so on. Therefore, it is necessary for emergency physicians to detect Kommerell's diverticulum and avoid premature discharge without consulting a thoracic surgeon for further treatment.

Dysphagia Lusoria - A Rare Cause of Prolonged Dysphagia

A 64-year-old man presented with prolonged history of intermittent dysphagia with sensation of food sticking at his upper chest. Physical examination was unremarkable, and an upper endoscopy did not reveal the underlying cause. On computed tomography scan of thorax, an aberrant right subclavian artery was seen coursing posterior to the esophagus resulting in external compression, which is a typical radiological feature of Dysphagia Lusoria. The pathophysiology, clinical features, imaging features and updated treatment modalities of this rare disease are discussed.

Aberrant Right Subclavian Artery (Arteria Lusoria): A Case Of Asymptomatic Rupture.

A 65-year-old male patient was referred to our hospital for sudden onset of shortness of breath and chest pain. His medical history had an abdominal aortic aneurysm about six years ago. His vital findings were normal. Laboratory findings showed leucocytosis (white blood cell count was 12 000/mm3, haemoglobin was 14.5gr/dl, and C-reactive protein value was 15 mg/dl). About four hours after the admittance to the hospital, ecchymosis occurred on his anterior neck region. The patient reported no discomfort on swallowing and did not have any history of previous important chest trauma or injury. A ruptured aberrant right subclavian artery (ARSA) was demonstrated by computed tomography-angiography and magnetic resonance angiography. To the best of our knowledge, this is the first case report of a patient presenting with ecchymosis on anterior neck region with acute onset due to the ruptured ARSA.

Hybrid Treatment of an Aortic Arch Aneurysm with an Aberrant Right Subclavian Artery / 대한내과학회지

Aberrant right subclavian artery (ARSA) is a rare congenital anomaly but is the most common of the congenital vascular anomalies of the aortic arch. We report the case of a 68-year-old female undergoing chemotherapy for multiple myeloma who had a large thoracic aortic aneurysm (7.4 cm) with ARSA. She was treated with a hybrid procedure that combined a left common carotid-to-subclavian artery bypass with a "thoracic endovascular aortic repair (TEVAR)" because of the risk associated with a thoracotomy. A stent graft was deployed in the proximal part of the descending aorta to cover the thoracic aortic aneurysm after a left common carotid-to-subclavian bypass was made to restore blood flow in the left arm. There was no endoleak on digital subtraction angiography. Hybrid therapy can be performed successfully for the treatment of thoracic aortic aneurysm with ARSA.

Tratamiento híbrido de arteria subclavia derecha aberrante / Hybrid treatment aberrant right subclavian artery

Introduction: An aberrant right subclavian artery is the most frequent aortic arch malformation. It is frequently an incidental finding of imaging studies and serious complications may arise if left untreated. Clinical case: We present a case of a young woman with a dilated aberrant right subclavian artery that was successfully treated by a hybrid approach.

Introducción: La arteria subclavia derecha aberrante es la malformación arterial más frecuente del arco aórtico. Su diagnóstico es habitualmente un hallazgo de estudios de imágenes solicitados por otras causas pero puede tener serias complicaciones si se obtiene en forma tardía. Caso clínico: Presentamos el caso de una mujer joven con diagnóstico de arteria subclavia lusoria dilatada sometida exitosamente a tratamiento híbrido electivo.

Surgical Treatment for Kommerell Diverticulm / 日本心臓血管外科学会雑誌

We report 3 surgical cases of aortic graft replacement with reconstruction of an aberrant subclavian artery (ASA) for Kommerell diverticulum (KD) and ASA. Cases 1 and 2 both had a right aortic arch, KD and a left ASA. In these 2 cases, we performed distal aortic arch replacement and <i>in-situ </i>reconstruction of the left ASA via a right thoracotomy. Case 3 had an aortic arch aneurysm, KD and a right ASA. In this patient, we chose median sternotomy and total aortic arch replacement, using 2 pieces of artificial grafts with 1 and 4 branches, respectively. The right ASA was reconstructed by end-to-side anastomosis between the right axillary artery and the side branch of the graft with 1 branch. In all 3 cases, cardiopulmonary bypass and deep hypothermia with a rectal temperature under 18°C were used in aortic graft replacement. In addition to deep hypothermia, either antegrade or retrograde cerebral perfusion was introduced, depending on the surgical situation, to provide additional brain protection. Selective ASA perfusion was performed in all patients during aortic graft replacement. In Case 1, aortic anastomosis was achieved while clamping, and cerebral perfusion was maintained via a cannula for aortic return at the ascending aorta. In Cases 2 and 3, aortic anastomosis was performed under deep hypothermic circulatory arrest, using retrograde and antegrade cerebral perfusion respectively in Cases 2 and 3. The postoperative course was uneventful in all 3 patients.

Arteria subclavia aberrante / Aberrant subclavian artery

Se estudiaron las variaciones en el origen y trayecto de la arteria subclavia derecha aberrante, observada en un cadáver utilizado para docencia de anatomía humana. En este caso, el arco aórtico da origen a cuatro ramas separadas, que de derecha a izquierda son: arteria carótida común derecha, arteria carótida común izquierda, arteria subclavia izquierda y arteria subclavia derecha. Desde este origen, la arteria subclavia derecha transcurre por detrás de la tráquea y del esófago, a la altura del cuerpo vertebral de T III, para luego retomar su trayecto normal hacia la raíz del cuello. Se midieron los diámetros del arco aórtico y de sus ramas. Asimismo, se consignaron los díametros y la distancia de origen de ambas arterias vertebrales, desde las arterias subclavias. Esto se realizó con el objeto de analizar posibles asimetrías importantes relacionadas con la aparición de esta variación. En el texto se discuten las probables razones embriológicas que permiten explicar el origen anómalo de la arteria subclavia derecha.

The anatomical variations involving the origin and passage of the right aberrant subclavian artery were studied, based on findings in a cadaver used for human anatomy teaching. In this case, the aortic arch gives rise to four separated branches, from right to left: right common carotid artery, left common carotid artery, left subclavian artery and right subclavian artery. From its origin, the right subclavian artery runs behind the trachea and esophagus, at the level of the third thoracic vertebrae, afterwards it reassumes its normal passage to the neck. The diameter of the aortic arch and its four branches were measured. In both vertebral arteries the diameter and distance from its origin in the subclavian arteries to the origin of the subclavian arteries were measured, with the purpose of analyzing potential important asymmetries. The probable embryologic explanations for this anomaly are discussed.

Disfagia lusoria: Reporte de un caso y revisión de literatura / Dysphagia lusoria: A case report and review of the literature

La compresión extrínseca del esófago por estructuras vasculares es una causa poco frecuente de disfagia; sin embargo, su diagnóstico es de gran importancia para ofrecer un adecuado manejo y disminuir la repercusión sobre la calidad de vida de los pacientes. Se presenta un caso ilustrativo de disfagia lusoria y posteriormente una revisión sobre su etiología, enfoque diagnóstico y manejo.

Extrinsic esophagus compression produced by vascular structures is a rare cause of dysphagia. Nevertheless, its diagnosis is critical to allow an appropriate management and to lower the impact on the patients’ quality of life. Here, an illustrative case of dysphagia lusoria is presented followed by a review of its etiology, diagnosis approach and its treatment.

A Non-recurrent Laryngeal Nerve that was Unnoticed in a Preoperative Imaging Study: A Case Report / 대한내분비외과학회지

A non-recurrent laryngeal nerve is a rare nerve anomaly that is associated with a developmentally aberrant subclavian artery. During thyroidectomy,this aberrant nerve may become inadvertently damaged, causing permanent ipsilateral vocal cord paralysis. However, it is possible to predict the presence of a non-recurrent laryngeal nerve by preoperative diagnosis of an aberrant subclavian artery. We report a case of thyroid surgery associated with a right non-recurrent laryngeal nerve that was unnoticed preoperatively in a CT scan of the neck, but was encountered incidentally during the thyroidectomy. The preoperative CT scan showed a retroesophageal aberrant right subclavian artery, but it was unnoticed. The female patient underwent a total thyroidectomy with central compartment node dissection for a thyroid cancer. The recurrent laryngeal nerve on the left side was identified, as was the non-recurrent laryngeal nerve on the right side. Postoperatively, the patient had normal vocal cord function. It is possible to predict preoperatively a right non-recurrent laryngeal nerve by identifying an aberrant right subclavian artery on the CT scan of the neck, which likely enables prevention of vocal cord paralysis.

Right aortic arch with aberrant left subclavian artery / 대한내과학회지

No abstract available.

Nonrecurrent Laryngeal Nerve / 대한내분비외과학회지

The nonrecurrent laryngeal nerve is a rare anomaly that may increase the risk of nerve injury during thyroid surgery. We experienced a case of nonrecurrent laryngeal nerve seen in a 35-year-old woman with adenomatous hyperplasia on her right thyroid. The nonrecurrent laryngeal nerve was incidentally found during the right thyroid lobectomy. It directly branched from the right vagus nerve and followed a transverse path parallel to the trunk of the inferior thyroid artery. The right lobectomy was performed with a careful preservation of the nerve. Postoperatively, the review of CT scan which was taken preoperatively revealed an aberrant right subclavian artery, which arose from the aortic arch and crossed behind the esophagus. To avoid an inadvertent injury to the nonrecurrent laryngeal nerve during thyroid surgery, it is important to be aware of the possibility of a nonrecurrent laryngeal nerve, particularly when an aberrant right subclavian artery is recognized preoperatively.