Endovascular management of a giant aortic arch aneurysm diverticulum: a case report

Thoracic aortic diverticulum, or Kommerell’s aneurysm, is a developmental outpouching at the anteromedial aspect of the thoracic aorta, specifically at the site of the aortic isthmus, with an incidence of up to 9% in adults. It represents a notable anatomical variation that, over time, undergoes aneurysmal dilatation, posing the risk of rupture.

We present a 66-year-old male initially referred with a 7.35 cm giant thoracic aortic arch diverticulum (TAD). It was initially discovered incidentally as a 2.1 cm type 3 Salomonowitz; however, it subsequently increased to 7.36 cm following the third COVID-19 infection with cytokine storm. He underwent a right-to-left carotid necklace C-shaped configuration cross-over bypass using an 8 mm ringed Dacron silver graft. Six weeks post-bypass, the patient underwent a successful repair of TAD using the NEXUS-Endospan-Artivion system (Artivion™, GA 30144, USA), employing a double inner branch to the innominate and left subclavian artery through a single groin approach. Postoperatively, he recovered fully without any neurological or cardiovascular issues with no signs of endoleaks, graft migration, or separation.

The saccular nature of the aneurysm at the arch reveals a distinctive set of challenges, mainly the low wall shear stress, which exposes their malignant potential, emphasizing the crucial need for intervention, especially when surpassing the critical 30 mm threshold. This premiere marks a significant milestone by introducing the ‘IDEALIST’ Artivion/Endospan Nexus, which pioneers a total endovascular approach post-CE marking, ushering in a new era in aortic arch interventions.