We read with great interest the article by Láinez-Ramos-Bossini and Ruiz-Carazo describing a total endovascular approach to treat a limited dissection of Kommerell diverticulum (KD) in a symptomatic patient.1

KD is an aneurysmal dilatation of the origin of an aberrant subclavian artery2 and as the authors pointed out, this arterial dilatation is reported to have an increased risk of rupture or dissection.3 Various interventional approaches have been proposed to treat KD, and since specific guidelines are still lacking, the choice of the best strategy depends on the patient's anatomical and clinical condition, availability of the most advanced devices and operator experience. Conventional open surgery has been the most widely utilized approach and different surgical techniques have been described to deal with a KD. However, this remains a hazardous and challenging option with non-negligible rates of postoperative complications.4

More recently, hybrid procedures and total endovascular repair have been proposed as being both feasible and effective. Aortic arch replacement using a ‘frozen elephant trunk’ technique with debranching of supra-aortic vessels, followed by thoracic endovascular aortic repair, has been demonstrated to be a possible alternative solution with excellent outcomes4,5; this strategy could represent a first-line option in asymptomatic patients with associated moderate or severe dilatation of the arch. On the other hand, if the proximal landing zone and the anatomy of the aortic arch appear suitable, a total endovascular repair currently most likely represents the best approach when non-surgical repair of KD is planned. In centers where specific skills have been acquired, owing to the rapid and significant developments in imaging and device technologies, a total endovascular intervention will also represent a procedure of choice in patients with KD, hopefully also making it easily reproducible.

Interestingly, the case reported by Láinez-Ramos-Bossini and Ruiz-Carazo underlines the importance of a multidisciplinary assessment that will enable the treatment to be tailored to the patient1 and we agree that the use of total endovascular treatment in patients with limited dissections of KD, particularly when they are referred as emergencies, may be a good option. Nevertheless, although it would be reasonable to consider total endovascular repair as a first choice for the treatment of KD associated with an aberrant subclavian artery, hybrid procedures and conventional open repair remain valid alternatives in patients without a suitable proximal landing zone and with severe expansion of the KD.