Case report: A rare cause of chest pain: Kommerell's diverticulum.

INTRODUCTION AND IMPORTANCE: Kommerell diverticulum is a very rare congenital defect of the aortic arch associated with the aberrant subclavian artery. It can present with signs of dysphagia, chest pain, or distal embolization in the upper limb. CASE PRESENTATION: We present a case of Kommerell diverticulum with associated large subclavian artery aneurysm in a male patient with chest pain of unknown origin and hypertension. There was an incidental finding of the wide mediastinum on chest X-ray and the patient had a difference in systolic blood pressure in both arms. A right thoracotomy incision was used to successfully excise the aneurysm and reconstruct the subclavian artery. Patient recovery was uneventful. CLINICAL DISCUSSION: Endovascular approaches are also an alternative to conventional open surgeries in the treatment of Kommerell diverticulum. CONCLUSION: Kommerell diverticulum with subclavian artery aneurysm should be considered in the differential diagnosis of non-cardiac chest pain. A simple investigation such as a chest X-ray can make a difference in these patients. Coarctation related to the right ASA might not always be a true coarctation. Endovascular treatment is an alternative to open repair in selected cases, but it needs further investigation in large randomized control trials.

Carotid Endarterectomy: A Single Institutional Experience of 28 Years From Pakistan.

BACKGROUND: Cerebrovascular event is the most common reason of acute neurological injury in the western world. There is an extensive literature and data available on its prognosis, outcomes and complications rates from the west, yet still, data regarding its safety and efficacy is scarce from the South Asian belt. OBJECTIVE: To elucidate the role of carotid endarterectomy in patients with carotid stenosis regarding prevention of stroke and safety of the procedure. METHODS: A descriptive case series of 335 consecutive patients from January 1990 till July 2018. All patients who underwent carotid endarterectomy were included. Patient having asymptomatic carotid disease (≥90%), history of a transient ischemic attack or patients with a recent or previous episode of ischemic stroke (≥60%) were selected for the procedure. All procedures were performed under GA. Post operatively patients were kept on antiplatelet therapy and followed on outpatient basis for any complications using carotid duplex scans. Data regarding 30-day postoperative parameters of the procedure were collected and evaluated. P< 0.05 is considered significant. RESULTS: A total of 335 carotid endarterectomies were performed. The majority of patients in our series were males 68.90% (n = 230) compared to 31.10% (n = 105) females (P< 0.05). There were no intraoperative mortalities in our patients. The 15-day perioperative mortality was 1.5% (n = 5), out of which 3 patients had concomitant CABG and died of cardiac complications. The mortality rate of CEA alone was 0.6% (n = 2). Six patients (1.8%) developed focal neurological deficits in the postoperative period during the hospital stay. Three patients developed wound infection after surgery. Neck hematoma formation occurred in 11.7% (n = 39) patients and 7 required immediate decompression. A total of 321 patients remained stroke free at 6 months follow up. There was no increased risk of stroke secondary to bilateral carotid disease (OR 1.9 CI 0.35-10.7 P= 0.44). CONCLUSION: Carotid Endarterectomy is a relatively safe and effective procedure in our large series from Pakistan. It remains the standard for management of carotid stenosis in symptomatic as well as asymptomatic patients with critical stenosis.