A Minimally Invasive, Off-pump, Prosthetic-free Technique for Repair of Aberrant Left Subclavian Artery and Kommerell Diverticulum in Adults with Right Aortic Arch

P0013 

Case Video Submission 

William Frankel (1), Matthew Thompson (2), Siva Raja (3), Michael Tong (4), Eric Roselli (4)

(1) Cleveland Clinic Foundation, Cleveland, OH, (2) Cleveland Clinic, Lakewood, OH, (3) Cleveland Clinic Foundation, Cleveland Ohio, OH, (4) Cleveland Clinic, Cleveland, OH

William Frankel    -  Contact Me
Cleveland Clinic Foundation

Matthew Thompson    -  Contact Me
Cleveland Clinic

*Siva Raja    -  Contact Me
Cleveland Clinic Foundation

*Michael Tong    -  Contact Me
Cleveland Clinic

*Eric Roselli    -  Contact Me
Cleveland Clinic

William Frankel    -  Contact Me
Cleveland Clinic Foundation

Objective: Aberrant left subclavian artery (ALSCA) with Kommerell diverticulum (KD) in adults with right aortic arch is a rare clinical entity, and consequently, data regarding indications for repair and optimal surgical approach are limited. We describe a minimally invasive staged approach for resection of KD and ALSCA revascularization without use of cardiopulmonary or prosthetic material.

Case Video Summary: After induction, the patient is intubated with a single-lumen endotracheal tube and placed in the left lateral decubitus position. Next, a right posterolateral thoracotomy is performed, sparing both the serratus anterior and latissimus dorsi muscles. As necessary, the 3rd or 4th rib is shingled to facilitate exposure. After the aortic arch is mobilized, the stump of the ALSCA and KD is identified and dissected down to the base, taking care to identify and avoid injury to surrounding structures. A side-biting clamp is applied, the stump is resected at its base, then closed with two layers of running 5-0 polypropylene suture and buttressed with bovine pericardium. After hemostasis, the thoracotomy is closed in usual fashion. All patients survived to discharge without major adverse event, transfusion, or re-exploration for bleeding. Median mechanical ventilation time was 6 hours. One patient had chylothorax requiring prolonged chest drainage and was discharged home on very low fat diet.

Conclusions: Advantages of this technique include avoidance of cardiopulmonary bypass and hypothermic circulatory arrest along with introduction of prosthetic material in young adults at lifetime risk of thromboembolic events and infection, yielding excellent early outcomes and durable relief of compressive esophageal and tracheobronchial symptoms.

Aortic Arch