Image in Cardiology
Limited dissection in Kommerell diverticulum of aberrant right subclavian artery
Dissecção limitada em divertículo de Kommerell na artéria subclávia direita aberrante
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Focal bulging of 21 mm×8 mm with a ‘mushroom cap’ appearance at a Kommerell diverticulum of the aberrant right subclavian artery (yellow arrows in A and B, black arrows in C-E). The latter compresses the esophagus posteriorly along its course to the right and passes 8 mm posterior to the right posterolateral margin of the trachea. The aortic size is within normal range and no other structural abnormalities of the aorta are observed. Note that vascular repair at this location may entail technical difficulties, particularly anchoring the endoprosthesis at the origin of the right subclavian artery. 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These two lesions showed isosignal intensity in T1-weighted images, and intense early (upper right panel, dashed arrow) and late (lower left panel, white arrows) gadolinium enhancement; Upper left panel: Positron emission tomography image shows increased <span class="elsevierStyleSup">68</span>Ga-DOTATOC uptake, further supporting the anatomic correspondence of these foci.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Gonçalves-Teixeira, Ricardo Ladeiras-Lopes, Nuno Dias Ferreira" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Gonçalves-Teixeira" ] 1 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Ladeiras-Lopes" ] 2 => array:2 [ "nombre" => "Nuno" "apellidos" => "Dias Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204921001926" "doi" => "10.1016/j.repce.2021.07.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] 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array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Intraoperative photograph showing site of distal anastomosis (arrow) in the left anterior descending coronary artery.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Magro, Nuno Carvalho, Rui Anjos, José Neves" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Magro" ] 1 => array:2 [ "nombre" => "Nuno" "apellidos" => "Carvalho" ] 2 => array:2 [ "nombre" => "Rui" "apellidos" => "Anjos" ] 3 => array:2 [ "nombre" => "José" "apellidos" => "Neves" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204921001902" "doi" => "10.1016/j.repce.2021.07.021" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => 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class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eduardo" "apellidos" => "Ruiz-Carazo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Radiology, University Hospital Virgen de las Nieves, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Radiology, University of Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Dissecção limitada em divertículo de Kommerell na artéria subclávia direita aberrante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1205 "Ancho" => 1505 "Tamanyo" => 297484 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography of the aorta, axial view (A), multiplanar reformatting in sagittal view (B), and volume rendering in oblique posterior views (C-E). Focal bulging of 21 mm×8 mm with a ‘mushroom cap’ appearance at a Kommerell diverticulum of the aberrant right subclavian artery (yellow arrows in A and B, black arrows in C-E). The latter compresses the esophagus posteriorly along its course to the right and passes 8 mm posterior to the right posterolateral margin of the trachea. The aortic size is within normal range and no other structural abnormalities of the aorta are observed. Note that vascular repair at this location may entail technical difficulties, particularly anchoring the endoprosthesis at the origin of the right subclavian artery. In addition, total exclusion of the dissected segment cannot always be achieved.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 73-year-old male patient presented to the emergency department with a chief complaint of central chest pain for the previous three days. His medical history revealed heavy smoking, hypertension and atrial fibrillation (AF). His physical examination, ECG, chest radiograph and laboratory tests were unremarkable (AF at 70-80 bpm). Due to lack of response to conservative drug treatment, an aortic computed tomography angiography (CTA) scan was performed, which detected a bulge with a ‘mushroom cap’ appearance in the posterior wall of an aberrant right subclavian artery (ARSA), reported as limited dissection (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> and Supplementary Videos A and B). After multidisciplinary committee assessment, it was decided to perform endovascular repair. A Gore endoprosthesis in a nitinol-covered stent was anchored at the origin of the left subclavian artery and an Amplatzer Vascular Plug was used to exclude the dissection of the ARSA from circulation. Initially, the patient evolved favorably but a few days later he presented an acute recurrence of chest pain. A new CTA showed signs of type III endoleak (Supplementary Video C), and emergent endovascular repair was planned. Unfortunately, after anesthetic induction, the patient presented severe hypotension with hemodynamic instability that quickly evolved to cardiogenic shock, multiorgan failure and, eventually, death.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Limited or subtle dissection is an uncommon form of acute aortic syndrome (AAS), and only a few case series have been published in the literature. Echocardiography and particularly CTA with cardiac gating can be considered the imaging modalities of choice because of their availability, speed and precision. The CTA appearance of limited dissection consists of an outward bulging oval or band-like luminal contour defect, resembling a mushroom cap. In the presence of these signs, emergent treatment is recommended, similarly to other types of AAS. Of note, Kommerell diverticulum has an increased risk of dissection and endovascular repair is a potential therapeutic strategy in limited dissections in this location, enabling the affected segment to be excluded. In this case, endovascular therapy was preferred over surgical treatment due to the patient's physical condition and the dissection type and location.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-24" "fechaAceptado" => "2020-06-11" "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0025" class="elsevierStylePara elsevierViewall">The following are the supplementary material to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0015" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1205 "Ancho" => 1505 "Tamanyo" => 297484 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography of the aorta, axial view (A), multiplanar reformatting in sagittal view (B), and volume rendering in oblique posterior views (C-E). Focal bulging of 21 mm×8 mm with a ‘mushroom cap’ appearance at a Kommerell diverticulum of the aberrant right subclavian artery (yellow arrows in A and B, black arrows in C-E). The latter compresses the esophagus posteriorly along its course to the right and passes 8 mm posterior to the right posterolateral margin of the trachea. The aortic size is within normal range and no other structural abnormalities of the aorta are observed. Note that vascular repair at this location may entail technical difficulties, particularly anchoring the endoprosthesis at the origin of the right subclavian artery. In addition, total exclusion of the dissected segment cannot always be achieved.</p>" ] ] 1 => array:7 [ "identificador" => "upi0005" "etiqueta" => "Supplementary Video A" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 1055436 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography of the aorta (axial view). Focal bulging with a ‘mushroom cap’ appearance (limited intimal tear) at the origin of the aberrant right subclavian artery (Kommerell diverticulum).</p>" ] ] 2 => array:7 [ "identificador" => "upi0010" "etiqueta" => "Supplementary Video B" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 1174117 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography of the aorta (volume rendering, rotational view). The focal bulging at the Kommerell diverticulum is shown.</p>" ] ] 3 => array:7 [ "identificador" => "upi0015" "etiqueta" => "Supplementary Video C" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 1980196 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Computed tomography angiography of the aorta (axial view images). The endoprosthesis location can be observed as well as filling of the supposedly excluded Kommerell diverticulum, suggestive of endoleak type III.</p>" ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004000000007/v1_202107090532/S0870255121001918/v1_202107090532/en/main.assets" "Apartado" => array:4 [ "identificador" => "75834" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Imagem em Cardiologia" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004000000007/v1_202107090532/S0870255121001918/v1_202107090532/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255121001918?idApp=UINPBA00004E" ]
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