During the 9th China Vascular Conference (CVC 2024), held on September 12, 2024, at the Chengdu Century City International Convention Center, the annual Top 10 Case Showcase of the Vascular Surgery Group of the Chinese Clinical Case Database was successfully held. Numerous surgical experts provided in-depth analysis and shared their experiences with the selected top 10 cases. Professor Ding Chenke from the Vascular Surgery Department of Zhongshan Hospital, Fudan University, shared a rare case of a right-sided aortic arch with Kommerell diverticulum. 

Case Sharing

Patient Information (Female, 68 years old)

Chief Complaint: Right shoulder and back pain with right upper limb numbness for six months, worsening over the past month.

Preoperative CTA: Right-sided aortic arch and descending thoracic aorta, left-sided aberrant subclavian artery; fusiform dilation of the aortic origin of the left subclavian artery with a diameter of approximately 30 mm and a distal lumen diameter of approximately 8 mm. Findings were consistent with a right-sided aortic arch and descending thoracic aorta with Kommerell diverticulum.

Additional Tests: Intracranial, neck, and cervical CTA showed no significant abnormalities.

Electromyography: Right C7-T1 nerve root damage, with mild right median nerve wrist damage on electrophysiological testing.

Case Characteristics

1. Symptoms of nerve compression in the right upper limb were consistent with compression caused by the right-sided arch and Kommerell diverticulum, after ruling out common orthopedic conditions.

2. CTA confirmed a Kommerell diverticulum with a basal diameter of approximately 30 mm, compressing the right thoracic outlet.

3. Orthopedic consultation suggested that the vascular anomaly was causing thoracic outlet syndrome.

Treatment Plan

Considering the patient’s age, overall condition, and preferences, fTEVAR (fenestrated thoracic endovascular aortic repair with bilateral subclavian artery fenestration and thoracic aortic endovascular repair) was chosen.

Modified Stent

• Aortic Stent: Ankura (32-28-200 mm), constricted.

• Right Subclavian Artery (RSA): Fenestrated.

• Left Subclavian Artery (LSA): Internal branch, Viabahn (8×15 mm).

Surgical Procedure

1. Left 9F long sheath and right 8F long sheath were inserted.

2.A large stent was delivered via the right femoral artery to the posterior edge of the left common carotid artery.

3. The stent was released, and the RSA fenestration opened.

4. The RSA was selected, balloon-fixed, and the large stent was released, retaining the constriction.

5. RSA Stent: Lifestream (10-38 mm).

6. The LSA internal branch was selected via the left femoral artery, and captured via the left brachial artery.

7. Pre-positioning of Sliverflow (12×80 mm) was completed, and the constriction was removed. The Sliverflow (12×80 mm) was then released.

8. The distal Sliverflow was positioned near the vertebral artery origin.

9. A BMS (Bare Metal Stent) liner (Absolute, 10×40 mm) was placed.

10. Post-expansion with a Mustang balloon (10×80 mm).

Immediate Postoperative Angiography: No endoleaks, branches were patent, and good flow was observed in the head vessels.

Clinical Outcome

The surgery was successful, and the patient was safely returned to the ward.

Day 1: Right shoulder and back pain and right upper limb numbness improved compared to before, but new left upper limb weakness developed. Physical examination showed the patient was alert but had slightly slurred speech, bilateral ptosis, a shallow left nasolabial fold, slight left tongue deviation, left upper limb muscle strength of Grade I, left lower limb muscle strength of Grade V-, and right limb muscle strength of Grade V. Neurology consultation diagnosed midbrain ischemic stroke. Treatment included dual antiplatelet therapy and statins, with Dingbenxi 100 ml bid and Semax 15 mg bid. Head MRI was scheduled.

Day 5: Head MRI showed multiple acute and subacute cerebral infarctions. Symptoms improved, and the patient was discharged for rehabilitation.

Follow-Up (1 month postoperatively): All signs of cerebral infarction had disappeared, and preoperative compression symptoms had completely resolved.

Follow-Up (3 months postoperatively): CTA showed a patent stent without endoleak.