Midterm Outcome of Aortic Dissection Associated With Aberrant Subclavian Artery: A Single-Center Retrospective Observational Study

Abstract

Purpose:

The aberrant subclavian artery (aSA) is a rare anomaly of the aortic branches. Approximately 20–60% of patients with an aSA are associated with Kommerell’s diverticulum (KD). These vascular anomalies have been reported to increase the risk of aortic rupture (4–19%) and aortic dissection. However, limited studies have investigated the treatment of aortic dissection in patients with aSA and KD. This study aims to investigate clinical characteristics and midterm follow-up outcomes of patients with aortic dissection associated with aSA.

Materials and methods:

Between 2011 and 2021, a total of 48 patients with aSA anomalies underwent aortic dissection surgical intervention. Surgical interventions include open surgery, hybrid surgery, and endovascular therapy. Among them, 20 (41.7%) had Stanford type A dissection, 9 (18.8%) had Stanford type B dissection, and 19 (39.6%) had non-A non-B dissection. We report the early and midterm clinical outcomes including mortality, central nervous system complication and respiratory complication, and other operative outcomes including reintervention rates and endoleak. A subgroup analysis of the surgical and postoperative conditions was performed on Stanford type B and non-A non-B aortic dissection patients.

Results:

The mean age of the patient population was 48.81±9.65 years. The 30-day mortality rate was 12.5%. The overall mortality rate was 20.8%, with a median follow-up time of 4.5 years (interquartile range [IQR]: 2–8.75 years). Central nervous system complications occurred in 8 patients (16.7%), subclavian steal syndrome in 6 patients (12.5%), and respiratory complications in 3 patients (6.2%). The estimated Kaplan–Meier survival rates at 1 year, 3 years, 5 years, and 7 years after surgery were, respectively, 87.0%, 82.5%, 79.7%, and 75.1%. For Stanford type B and non-A non-B aortic dissection patients, the 30-day mortality rate between the open surgery group and the minimally invasive group had no statistically significant differences (18.3% vs 8.3%, p=0.815).

Conclusions:

Surgical intervention for aSA patients with aortic dissection has poor outcomes. Early intervention might be considered for patients with aSA and KD to prevent the occurrence of aortic dissection.

Clinical Impact

Aberrant subclavian artery (aSA) and Kommerell’s diverticulum (KD) have been reported to increase the risk of aortic rupture and aortic dissection. This study is currently the largest single-center retrospective study on aSA combined with aortic dissection, providing standardized data reporting and midterm follow-up of patients with this rare vascular anomaly.

Keywords

aberrant subclavian artery Kommerell’s diverticulum aortic dissection thoracic endovascular aortic repair frozen elephant trunk

Get full access to this article

View all access options for this article.

References

Giuliani

Di Toro

Urtis

, et al Prevalence and complications of aberrant subclavian artery in patients with heritable and nonheritable arteriopathies. J Am Coll Cardiol. 2023;81(10):979–991. doi:10.1016/j.jacc.2023.01.005.

Natsis

Didagelos

Gkiouliava

, et al The aberrant right subclavian artery: cadaveric study and literature review. Surg Radiol Anat. 2017;39(5):559–565. doi:10.1007/s00276-016-1796-5.

Vinnakota

Idrees

Rosinski

, et al Outcomes of repair of Kommerell diverticulum. Ann Thorac Surg. 2019;108(6):1745–1750. doi:10.1016/j.athoracsur.2019.04.122.

Yousef

Singh

Alkukhun

, et al Variants of the aortic arch in adult general population and their association with thoracic aortic aneurysm disease. J Card Surg. 2021;36(7):2348–2354. doi:10.1111/jocs.15563.

Tanaka

Milner

Ota

Kommerell’s diverticulum in the current era: a comprehensive review. Gen Thorac Cardiovasc Surg. 2015;63(5):245–259. doi:10.1007/s11748-015-0521-3.

Luciano

Mitchell

Fraisse

, et al Kommerell diverticulum should be removed in children with vascular ring and aberrant left subclavian artery. Ann Thorac Surg. 2015;100(6):2293–2297. doi:10.1016/j.athoracsur.2015.06.093.

Nishioka

Iba

Bochimoto

, et al Ultrastructural features of the aortic wall in a patient with Kommerell diverticulum. Ann Vasc Surg. 2021;74:525.e1–525.e6. doi:10.1016/j.avsg.2021.02.036.

Kommerell

Verlagerung des ösophagus durch eine abnorm verlaufende arteria subclavia dextra (arteria lusoria). Fortschr Geb Roentgenstrahlen. 1936;54:590–595.

Konstantinou

Antonopoulos

Tzanis

, et al Systematic review and meta-analysis of outcomes after operative treatment of aberrant subclavian artery pathologies and suggested reporting items. Eur J Vasc Endovasc Surg. 2022;63(5):759–767. doi:10.1016/j.ejvs.2022.02.027.

10.

Howard

Ponnapalli

Shaikh

, et al Non-A non-B aortic dissection: a literature review. J Card Surg. 2021;36(5):1806–1813. doi:10.1111/jocs.15349.

11.

Kreibich

Rylski

Bavaria

, et al Outcome after operation for aortic dissection type A in morbidly obese patients. Ann Thorac Surg. 2018;106(2):491–497. doi:10.1016/j.athoracsur.2018.03.035.

12.

Isselbacher

Preventza

Hamilton Black

, et al 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: a report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2022;146(24):e334–e482. doi:10.1161/CIR.0000000000001106.

13.

Pape

Awais

Woznicki

, et al Presentation, diagnosis, and outcomes of acute aortic dissection. J Am Coll Cardiol. 2015;66(4):350–358. doi:10.1016/j.jacc.2015.05.029.

14.

Bath

D’Oria

Rogers

, et al Contemporary outcomes after treatment of aberrant subclavian artery and Kommerell’s diverticulum. J Vasc Surg. 2023;77(5):1339–1348.e6. doi:10.1016/j.jvs.2023.01.014.

15.

Czerny

Schmidli

Adler

, et al Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Cardiothorac Surg. 2019;55(1):133–162. doi:10.1093/ejcts/ezy313.

16.

Jalaie

Grommes

Sailer

, et al Treatment of symptomatic aberrant subclavian arteries. Eur J Vasc Endovasc Surg. 2014;48(5):521–526. doi:10.1016/j.ejvs.2014.06.040.

17.

Fukuhara

Ahmed

Shiomi

, et al Aberrant subclavian arteries and associated Kommerell diverticulum: endovascular vs open repair. Ann Thorac Surg. 2022;114(6):2163–2171. doi:10.1016/j.athoracsur.2021.09.065.

18.

Naoum

Parenti

LeMaire

, et al Endovascular repair of a right-sided descending thoracic aortic aneurysm with a right-sided aortic arch and aberrant left subclavian artery. Ann Thorac Surg. 2008;85(3):1074–1076. doi:10.1016/j.athoracsur.2007.09.032.

19.

Rylski

Branchetti

Bavaria

, et al Modeling of predissection aortic size in acute type A dissection: more than 90% fail to meet the guidelines for elective ascending replacement. J Thorac Cardiovasc Surg. 2014;148(3):944–948.e1. doi:10.1016/j.jtcvs.2014.05.050.

20.

Molz

Burri

Aberrant subclavian artery (arteria lusoria): sex differences in the prevalence of various forms of the malformation. Evaluation of 1378 observations. Virchows Arch A Pathol Anat Histol. 1978;380(4):303–315. doi:10.1007/BF00431315.

21.

Tanaka

Natsume

, et al Successful surgical exclusion of rapidly expanding Kommerell diverticulum following a total arch replacement for an acute type A aortic dissection. Ann Vasc Dis. 2014;7(3):339–342. doi:10.3400/avd.cr.14-00027.