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Eur J Cardiothorac Surg 2002;22:1039
© 2002 Elsevier Science NL

Letter to the Editor

Reply to Konstantinov

Carl L. Backer*

Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, 2300 Children's Plaza, M/C 22, Chicago, IL 60614, USA

Received 11 September 2002; accepted 17 September 2002.

* Tel.: +1-773-880-4378; fax: +1-773-880-3054
e-mail: cbacker{at}childrensmemorial.org

Key Words: Kommerell's diverticulum • Circumflex aorta • Artery

Dr Konstantinov has pointed out several important issues regarding patients with a right aortic arch, Kommerell's diverticulum, left ligamentum, and retroesophageal left subclavian artery. In particular the group of patients having (in addition) the so-called ‘circumflex aorta’, require a more extensive procedure than simple diverticulum excision, ligamentum division, and subclavian artery transfer. These patients require either the operation described by Dr Konstantinov – extra-anatomic reconstruction [1], or transection of the aorta with translocation anterior to the trachea as described by Robotin and colleagues [2]. These patients are quite rare and in fact I have never performed this operation, although I have one patient currently referred for that procedure. Robotin and colleagues describe this operation in three patients in their series of over 500 patients with vascular rings.

I agree completely with Dr Konstantinov with regard to the importance of transferring the left subclavian artery. In our manuscript published in the European Journal of Cardio-thoracic Surgery [3] we had only one patient who had undergone this procedure as a primary operation. I have now operated on three patients where I have as a primary procedure resected the Kommerell's diverticulum, divided the ligamentum, and transferred the left subclavian artery to the left carotid artery. As our understanding of the pathophysiology of these patients increases it is my belief that this will become a much more common procedure.

A corollary to this is that I now recommend radiographic imaging studies – either a computed tomography scan with contrast or a magnetic resonance angiography to delineate the exact vascular anatomy prior to the intervention. If one is forewarned with regard to the possibility of a Kommerell's diverticulum (or a circumflex aorta) this can be dealt with at the time of the primary procedure and not require reoperation as was performed on the majority of patients in our published manuscript. This increased preoperative information beyond what can be obtained with a barium swallow is critically important to planning the proper operation.

I thank Dr Konstantinov for pointing out the important group of patients with a circumflex aorta that may need a more extensive operation than the one we have described in our manuscript. I also thank him for the important discussion regarding the sling-like effect of the left subclavian artery on patients with a right aortic arch and the importance of dividing and transferring the left subclavian artery.

References

  1. Konstantinov I.E., Puga F.J. Surgical treatment of persistent esophageal compression by an unusual form of right aortic arch. Ann Thorac Surg 2001;72:2121-2123.[Abstract/Free Full Text]
  2. Robotin M.C., Bruniaux J., Serraf A., Uva M.S., Roussin R., Lacour-Gayet F., Planche C. Unusual forms of tracheobronchial compression in infants with congenital heart disease. J Thorac Cardiovasc Surg 1995;112:415-423.[Abstract/Free Full Text]
  3. Backer C.L., Hillman N., Mavroudis C., Holinger L.D. Resection of Kommerell's diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division. Eur J Cardiothorac Surg 2002;22:64-69.[Abstract/Free Full Text]




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