From the Guidelines
The management approach for aortic ductus diverticulum typically involves conservative observation, as it is often a normal anatomical variant rather than a pathological condition, but surgical intervention may be advised for Kommerell’s diverticulum when the diverticulum orifice is >3.0 cm or the combined diameter of the diverticulum and adjacent descending aorta is >5.0 cm, or both, as recommended by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1 and the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1.
Key Considerations
- Aortic ductus diverticulum represents a small outpouching at the site of the closed ductus arteriosus in the descending thoracic aorta, just distal to the origin of the left subclavian artery.
- No specific medications or interventions are required for this finding when identified incidentally on imaging studies, but regular cardiovascular health maintenance is appropriate, including blood pressure control if hypertension is present.
- The diverticulum should be differentiated from a true aortic aneurysm or pseudoaneurysm, which would require different management approaches, through appropriate imaging such as CT angiography or MRI.
- Kommerell’s diverticulum, a remnant of the fourth dorsal aortic arch due to incomplete regression, may be present in 20%–60% of those with an aberrant subclavian artery and carries a risk of rupture or dissection, with surgical intervention advised for larger diverticula or those with specific diameter criteria, as supported by the guidelines 1.
Management Approach
- Conservative observation is generally recommended for aortic ductus diverticulum, with a focus on regular cardiovascular health maintenance.
- Surgical consultation for potential repair may be considered in rare cases where the diverticulum is unusually large or associated with symptoms, or when Kommerell’s diverticulum meets specific criteria for intervention, as outlined in the guidelines 1.
- Successful repair has been described using open, endovascular, or hybrid approaches, depending on patient anatomy, comorbidities, and expertise, as noted in the 2022 ACC/AHA guideline 1 and the 2024 ESC guidelines 1.
From the Research
Management Approach for Aortic Ductus Diverticulum
The management approach for aortic ductus diverticulum involves several key considerations, including:
- Diagnosis: Diagnosis may be difficult and may require multiple-view aortography or computed tomographic (CT) scanning to differentiate from tumor 2.
- Operative Approach: The operative approach, either left thoracotomy or median sternotomy, may be determined by the necessity for concomitant procedures 2.
- Repair: Aneurysms can be repaired effectively by aneurysmorrhaphy, unlike true atherosclerotic aneurysms of the aortic arch 2.
- Indications for Surgery: Aneurysms greater than 3 cm in diameter, those producing symptoms, or those showing progressive enlargement should be surgically resected 2.
- Associated Conditions: Ductus diverticulum aneurysm can be associated with other conditions, such as bicuspid aortic valve and dilatation of ascending aorta 3.
- Traumatic Rupture: Traumatic rupture of the aorta with ductus diverticulum is a life-threatening injury that requires prompt diagnosis and surgical repair 4.
- Surgical Treatment: Surgical resection should be performed in patients with risk factors for major complications, such as male gender, fibrous type, and subaortic diverticulum 5.
Key Considerations
- Accurate diagnosis is crucial to determine the appropriate management approach 2, 4.
- Surgical treatment should be considered for patients with aneurysms greater than 3 cm in diameter, those producing symptoms, or those showing progressive enlargement 2.
- Associated conditions, such as bicuspid aortic valve and dilatation of ascending aorta, should be taken into account when determining the management approach 3.
- Traumatic rupture of the aorta with ductus diverticulum requires prompt diagnosis and surgical repair 4.